Provider Demographics
NPI:1326769399
Name:SIMON, SAM (CRNP)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 MONUMENT ROAD
Mailing Address - Street 2:OUTPATIENT BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1689
Mailing Address - Country:US
Mailing Address - Phone:215-877-2000
Mailing Address - Fax:
Practice Address - Street 1:4200 MONUMENT ROAD
Practice Address - Street 2:OUTPATIENT BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1689
Practice Address - Country:US
Practice Address - Phone:215-877-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN675125163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult