Provider Demographics
NPI:1265514624
Name:SIMMONS, CALVIN ROBERT (NP)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:ROBERT
Last Name:SIMMONS
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 1:1001 W FAYETTE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-476-1792
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:POB NORTH, SUITE 2S
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5791
Practice Address - Fax:315-492-5855
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333058363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00636888Medicare PIN
NYQ65173Medicare UPIN
NYRB2350Medicare PIN
NYP00439029Medicare PIN