Provider Demographics
NPI:1114906849
Name:SIMMS, JOHN (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SIMMS
Suffix:
Gender:M
Credentials:PA
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 657
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-0657
Mailing Address - Country:US
Mailing Address - Phone:706-865-4001
Mailing Address - Fax:706-865-6268
Practice Address - Street 1:17 WHITE ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-1140
Practice Address - Country:US
Practice Address - Phone:706-865-4001
Practice Address - Fax:706-865-6268
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001266363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000487EMedicaid
GAR94252Medicare UPIN
GA93BBHMCMedicare ID - Type Unspecified