Provider Demographics
NPI:1336820976
Name:JACQUEZ, SIMON PEDRO (PA)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:PEDRO
Last Name:JACQUEZ
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 1:6211 N 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-1415
Mailing Address - Country:US
Mailing Address - Phone:602-242-5000
Mailing Address - Fax:480-605-2291
Practice Address - Street 1:6211 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-1415
Practice Address - Country:US
Practice Address - Phone:602-242-5000
Practice Address - Fax:480-605-2291
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9856363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical