Provider Demographics
NPI:1295030963
Name:SIMON, MICHAEL LAWRENCE (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:SIMON
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 15321
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07192-5321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:416 BELLEVUE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-4513
Practice Address - Country:US
Practice Address - Phone:609-396-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00317200367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered