Healthcare Provider Details

I. General information

NPI: 1417580416
Provider Name (Legal Business Name): DEAN J ZIMMERMANN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 SOUTHPARK CIR E
SAINT AUGUSTINE FL
32086-5137
US

IV. Provider business mailing address

12109 COUNTY ROAD 103
OXFORD FL
34484-2951
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-1450
  • Fax:
Mailing address:
  • Phone: 352-205-8981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112964
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: