Provider Demographics
NPI:1174118871
Name:MOMPREMIER, MYRTHIL DIT JIMMY (PA)
Entity type:Individual
Prefix:
First Name:MYRTHIL
Middle Name:DIT JIMMY
Last Name:MOMPREMIER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3140 N 35TH AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-5270
Mailing Address - Country:US
Mailing Address - Phone:602-353-6656
Mailing Address - Fax:602-442-2065
Practice Address - Street 1:3140 N 35TH AVE STE 7
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-5270
Practice Address - Country:US
Practice Address - Phone:602-353-6656
Practice Address - Fax:602-442-2065
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ9621363A00000X
FL32146207Q00000X
PR32146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant