Basic Information
| Provider Information | |||||||||
| NPI: | 1952322299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZIMNEY | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 E MILL ST, PO BOX 737 | ||||||||
| Address2: | |||||||||
| City: | PELICAN RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188636100 | ||||||||
| FaxNumber: | 2188636173 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 E MILL ST | ||||||||
| Address2: | |||||||||
| City: | PELICAN RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188636100 | ||||||||
| FaxNumber: | 2188636173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 11/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 9966 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 483903000 | 05 | MN | MEDICAID | 71194 | 05 | ND | MEDICAID |