Basic Information
| Provider Information | |||||||||
| NPI: | 1013528900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIMBACH | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 EAST MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185464400 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 EAST MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185464400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2020 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 13451 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.