Provider Demographics
NPI:1184773897
Name:SIMMONS, JEROME E (PA)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:E
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 S. MAIN
Mailing Address - Street 2:
Mailing Address - City:BLANCHARDVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53516
Mailing Address - Country:US
Mailing Address - Phone:608-523-4261
Mailing Address - Fax:
Practice Address - Street 1:309 S. MAIN
Practice Address - Street 2:
Practice Address - City:BLANCHARDVILLE
Practice Address - State:WI
Practice Address - Zip Code:53516
Practice Address - Country:US
Practice Address - Phone:608-523-4261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R97705Medicare UPIN