Provider Demographics
NPI:1023361128
Name:SIMON, DOUGLAS PAUL (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PAUL
Last Name:SIMON
Suffix:
Gender:M
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 1:106 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:GOODLAND
Mailing Address - State:KS
Mailing Address - Zip Code:67735-1518
Mailing Address - Country:US
Mailing Address - Phone:785-890-6075
Mailing Address - Fax:785-890-6077
Practice Address - Street 1:106 WILLOW RD
Practice Address - Street 2:
Practice Address - City:GOODLAND
Practice Address - State:KS
Practice Address - Zip Code:67735-1518
Practice Address - Country:US
Practice Address - Phone:785-890-6075
Practice Address - Fax:785-890-6077
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant