Provider Demographics
NPI:1609968783
Name:GRIFFIN, SIMONE WENDY (PA)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:WENDY
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SIMONE
Other - Middle Name:WENDY
Other - Last Name:TELFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:821 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-3453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:821 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-3453
Practice Address - Country:US
Practice Address - Phone:209-826-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH363A00000X
CA53276363A00000X
GA004693363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA369559693BMedicaid