Provider Demographics
NPI:1740772250
Name:SIMONTON, TYLER B (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:B
Last Name:SIMONTON
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:TYLER
Other - Middle Name:B
Other - Last Name:CHANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 W MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1254
Practice Address - Country:US
Practice Address - Phone:317-779-0303
Practice Address - Fax:317-737-2149
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006830363A00000X
GA12953363A00000X
IN10003593A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00450054OtherRAILROAD PTAN
IN300069733Medicaid
IN1740772250OtherANTHEM PTAN