Provider Demographics
NPI:1013766625
Name:SIMONS, MARIAH HELENE (PA)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:HELENE
Last Name:SIMONS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:108 SPLIT ROCK RD
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:NY
Mailing Address - Zip Code:13646-4252
Mailing Address - Country:US
Mailing Address - Phone:315-771-4081
Mailing Address - Fax:
Practice Address - Street 1:75 BEEKMAN ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1438
Practice Address - Country:US
Practice Address - Phone:518-561-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032098-01363A00000X
NY032098363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty