Provider Demographics
NPI:1114944741
Name:SIMMONS, NICHOLAS RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:RAY
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:MD
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 21040
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-7197
Mailing Address - Country:US
Mailing Address - Phone:509-473-7672
Mailing Address - Fax:
Practice Address - Street 1:800 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2803
Practice Address - Country:US
Practice Address - Phone:509-473-7672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005004445207L00000X
WAMD60974769207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO930820174Medicaid
336OtherMO-BLUE SHIELD
MO930820174Medicaid