Provider Demographics
NPI:1972266252
Name:SIMON, COLLEEN JULIA (PA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:JULIA
Last Name:SIMON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 S CULVER TER
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-7719
Mailing Address - Country:US
Mailing Address - Phone:517-331-0793
Mailing Address - Fax:
Practice Address - Street 1:6301 MEMORIAL HWY STE 303
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4573
Practice Address - Country:US
Practice Address - Phone:813-298-0658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010767363A00000X
FL9114879363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant