Provider Demographics
NPI:1780216010
Name:SIMPSON, MILO JACKSON (PA-C)
Entity Type:Individual
Prefix:
First Name:MILO
Middle Name:JACKSON
Last Name:SIMPSON
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 1:17036 POND CIR
Mailing Address - Street 2:
Mailing Address - City:BON AQUA
Mailing Address - State:TN
Mailing Address - Zip Code:37025-3193
Mailing Address - Country:US
Mailing Address - Phone:615-351-2245
Mailing Address - Fax:
Practice Address - Street 1:2340 FAIRVIEW BLVD STE 600D
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:TN
Practice Address - Zip Code:37062-9457
Practice Address - Country:US
Practice Address - Phone:615-266-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant