Provider Demographics
NPI:1326216789
Name:SIMON, TIFFANY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:SIMON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:ANN
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:701 S NEW BALLAS RD STE 510
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8726
Mailing Address - Country:US
Mailing Address - Phone:314-251-6710
Mailing Address - Fax:
Practice Address - Street 1:701 S NEW BALLAS RD STE 510
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8726
Practice Address - Country:US
Practice Address - Phone:314-251-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008005003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1326216789Medicaid
ILENROLLEDMedicaid