Provider Demographics
NPI:1326190703
Name:ZIMMERMAN, BRENDA L (PAC)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:L
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:2351 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-6333
Practice Address - Country:US
Practice Address - Phone:920-651-8855
Practice Address - Fax:920-385-0287
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2877-23363AM0700X
WI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP83420Medicare UPIN