Healthcare Provider Details

I. General information

NPI: 1477265155
Provider Name (Legal Business Name): ALEXIS MIA DIMO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25950 DIXIE HWY STE 400
PERRYSBURG OH
43551-2983
US

IV. Provider business mailing address

25950 DIXIE HWY STE 400
PERRYSBURG OH
43551-2983
US

V. Phone/Fax

Practice location:
  • Phone: 567-585-0010
  • Fax: 567-225-3490
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008598RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012276
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: