Healthcare Provider Details

I. General information

NPI: 1962206813
Provider Name (Legal Business Name): SIMON GRAY LOOS PA-S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N. 1ST ST., BUILDING 46
APO AA
73521
US

IV. Provider business mailing address

301 N. 1ST ST., BUILDING 46
APO AA
73521
US

V. Phone/Fax

Practice location:
  • Phone: 580-481-6084
  • Fax:
Mailing address:
  • Phone: 580-481-6084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: