Provider Demographics
NPI:1245662048
Name:KATUMU, SIMON M (NP)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:M
Last Name:KATUMU
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8833 PACIFIC AVE STE D
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-6490
Mailing Address - Country:US
Mailing Address - Phone:253-212-0272
Mailing Address - Fax:253-254-7043
Practice Address - Street 1:8833 PACIFIC AVE STE D
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-6490
Practice Address - Country:US
Practice Address - Phone:253-212-0272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013013676363LF0000X
WAAP60978479363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01260164OtherRAILROAD MEDICARE IL
MOP01260158OtherRAILROAD MEDICARE MO
IL$$$$$$$$$001Medicaid
ILP01260164OtherRAILROAD MEDICARE IL
MOMA4343003Medicare PIN