Provider Demographics
NPI:1649565375
Name:SIMONSON, MIRA M (PT)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:M
Last Name:SIMONSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35249 KENAI SPUR HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7623
Mailing Address - Country:US
Mailing Address - Phone:907-420-0836
Mailing Address - Fax:
Practice Address - Street 1:35249 KENAI SPUR HWY
Practice Address - Street 2:STE C
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7623
Practice Address - Country:US
Practice Address - Phone:907-420-0836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1027662251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic