Healthcare Provider Details

I. General information

NPI: 1649565375
Provider Name (Legal Business Name): MIRA M SIMONSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35249 KENAI SPUR HWY STE C
SOLDOTNA AK
99669-7623
US

IV. Provider business mailing address

35249 KENAI SPUR HWY SUITE C
SOLDOTNA AK
99669-7623
US

V. Phone/Fax

Practice location:
  • Phone: 907-420-0836
  • Fax:
Mailing address:
  • Phone: 907-420-0836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number102766
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: