Provider Demographics
NPI:1285266718
Name:WILEY, MIMI ERIN (PA-C)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:ERIN
Last Name:WILEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W CATAWISSA ST
Mailing Address - Street 2:
Mailing Address - City:NESQUEHONING
Mailing Address - State:PA
Mailing Address - Zip Code:18240-1501
Mailing Address - Country:US
Mailing Address - Phone:570-669-9787
Mailing Address - Fax:570-669-9785
Practice Address - Street 1:108 W CATAWISSA ST
Practice Address - Street 2:
Practice Address - City:NESQUEHONING
Practice Address - State:PA
Practice Address - Zip Code:18240-1501
Practice Address - Country:US
Practice Address - Phone:570-669-9787
Practice Address - Fax:570-669-9785
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant