Provider Demographics
NPI:1740212190
Name:SIMMONS, STEVEN BOE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:BOE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2600
Mailing Address - Country:US
Mailing Address - Phone:208-233-2100
Mailing Address - Fax:208-233-3146
Practice Address - Street 1:2240 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2600
Practice Address - Country:US
Practice Address - Phone:208-233-2100
Practice Address - Fax:208-233-3146
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805765100Medicaid
IDS97763Medicare UPIN
ID1666483Medicare PIN