Provider Demographics
NPI:1073782454
Name:SIMMONS, BARRY (CRNA)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2329
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-7329
Mailing Address - Country:US
Mailing Address - Phone:360-466-2542
Mailing Address - Fax:360-466-2682
Practice Address - Street 1:111 S 13TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4105
Practice Address - Country:US
Practice Address - Phone:360-336-2178
Practice Address - Fax:360-466-2682
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00141817367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0230103OtherDEPARTMENT OF LABOR AND INDUSTRIES
WA9655846Medicaid
WA0230103OtherDEPARTMENT OF LABOR AND INDUSTRIES