Provider Demographics
NPI:1083003529
Name:SIMONS, SEAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:
Last Name:SIMONS
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10330 SE 32ND AVE STE 205
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6594
Practice Address - Country:US
Practice Address - Phone:503-513-8950
Practice Address - Fax:503-513-8951
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA170896363A00000X
OR363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500682764Medicaid
ORP01502233OtherRAILROAD MEDICARE
ORR179264Medicare PIN
ORP01502233OtherRAILROAD MEDICARE
OR161133OtherGROUP MEDICAID NORTH BEND MEDICAL CENTER
ORP01502233OtherRAILROAD MEDICARE
ORR179264Medicare PIN