Healthcare Provider Details

I. General information

NPI: 1922917582
Provider Name (Legal Business Name): ERIC MIMM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N DUKE ST
LANCASTER PA
17602-2207
US

IV. Provider business mailing address

30 DOVER CT
MORGANTOWN PA
19543-8811
US

V. Phone/Fax

Practice location:
  • Phone: 717-544-5511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA068152
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: