Provider Demographics
NPI:1922589365
Name:SIMONSEN, RACHEL DIANE (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:DIANE
Last Name:SIMONSEN
Suffix:
Gender:F
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-926-9022
Mailing Address - Fax:215-926-9022
Practice Address - Street 1:1741 FRANKFORD AVE STE 100A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-2445
Practice Address - Country:US
Practice Address - Phone:215-425-2424
Practice Address - Fax:215-425-0342
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035566360004Medicaid