Provider Demographics
NPI:1275712838
Name:SIMON, DESSERAY
Entity Type:Individual
Prefix:
First Name:DESSERAY
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 PARK ST
Mailing Address - Street 2:APT 206
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7702
Mailing Address - Country:US
Mailing Address - Phone:651-983-9311
Mailing Address - Fax:
Practice Address - Street 1:1501 PARK ST
Practice Address - Street 2:APT 206
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55110-7702
Practice Address - Country:US
Practice Address - Phone:651-983-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist