Provider Demographics
NPI:1255998944
Name:SIMPLECLINIC PLLC
Entity type:Organization
Organization Name:SIMPLECLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:910-491-4530
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:STEDMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28391-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-3827
Practice Address - Country:US
Practice Address - Phone:910-491-9418
Practice Address - Fax:866-488-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-29
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPENDINGMedicaid