Provider Demographics
NPI:1881621753
Name:SIMON, MIRIAM J (PA)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:J
Last Name:SIMON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9811
Mailing Address - Country:US
Mailing Address - Phone:802-748-9405
Mailing Address - Fax:802-748-4540
Practice Address - Street 1:NVRH CORNER MEDICAL
Practice Address - Street 2:195 INDUSTRIAL PKWY
Practice Address - City:LYNDON
Practice Address - State:VT
Practice Address - Zip Code:05849
Practice Address - Country:US
Practice Address - Phone:802-748-9501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1002900Medicaid
NH3075309Medicaid
VTS00777Medicare UPIN
VTAP1383Medicare PIN