Provider Demographics
NPI:1932605433
Name:NDELY, SIMON-NOEL
Entity Type:Individual
Prefix:
First Name:SIMON-NOEL
Middle Name:
Last Name:NDELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 13TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-4220
Mailing Address - Country:US
Mailing Address - Phone:612-877-2426
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-365-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNS479125347520208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics