Provider Demographics
NPI:1326397993
Name:SIMON, BRENT (PA)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1234
Mailing Address - Country:US
Mailing Address - Phone:989-892-7722
Mailing Address - Fax:989-892-7455
Practice Address - Street 1:204 W 3RD ST
Practice Address - Street 2:
Practice Address - City:PINCONNING
Practice Address - State:MI
Practice Address - Zip Code:48650-9622
Practice Address - Country:US
Practice Address - Phone:989-879-3771
Practice Address - Fax:989-879-3788
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1566OtherPTAN GROUP
MI1326397993Medicaid
MI1326397993Medicaid
MIN11800012Medicare UPIN
MIMI1566006Medicare UPIN