Healthcare Provider Details

I. General information

NPI: 1477175446
Provider Name (Legal Business Name): MIMI HARZAN MSPA, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIMI CHARTER MSPA, PA-C

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE NEFF RD STE 302
BEND OR
97701-4279
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-6915
  • Fax: 541-706-6733
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008538
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: