Provider Demographics
NPI:1134854813
Name:FORT, SIMONE TAIJAE PERSON (PA-C)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:TAIJAE PERSON
Last Name:FORT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SIMONE
Other - Middle Name:T
Other - Last Name:PERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10150 HIGHLAND MANOR DR STE 205
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-9727
Mailing Address - Country:US
Mailing Address - Phone:813-259-1013
Mailing Address - Fax:813-254-0396
Practice Address - Street 1:10150 HIGHLAND MANOR DR STE 205
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-9727
Practice Address - Country:US
Practice Address - Phone:813-259-1013
Practice Address - Fax:813-254-0396
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116104363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant