Healthcare Provider Details

I. General information

NPI: 1619526217
Provider Name (Legal Business Name): JEAN SIMON JOEL EDOUARD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6739 W CACTUS RD
PEORIA AZ
85381-5311
US

IV. Provider business mailing address

6739 W CACTUS RD
PEORIA AZ
85381-5311
US

V. Phone/Fax

Practice location:
  • Phone: 520-527-8038
  • Fax: 623-889-0814
Mailing address:
  • Phone: 520-527-8038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNJDCATEMP-000588
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number21-308
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01253
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000430-P.A
License Number StatePR
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberNJDCATEMP-00291
License Number StateNJ
# 6
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8276
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: