Provider Demographics
NPI:1578645594
Name:SIMON, WILLIAM R JR (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:SIMON
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1053
Mailing Address - Country:US
Mailing Address - Phone:316-448-8339
Mailing Address - Fax:316-221-7149
Practice Address - Street 1:2230 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1053
Practice Address - Country:US
Practice Address - Phone:316-448-8339
Practice Address - Fax:316-221-7149
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO796363A00000X
KS15-00201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS003719362OtherKANSAS MEDICARE
CO07007966Medicaid
KS201100640BMedicaid