Healthcare Provider Details

I. General information

NPI: 1023361128
Provider Name (Legal Business Name): DOUGLAS PAUL SIMON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2012
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 WILLOW RD
GOODLAND KS
67735-1518
US

IV. Provider business mailing address

106 WILLOW RD
GOODLAND KS
67735-1518
US

V. Phone/Fax

Practice location:
  • Phone: 785-890-6075
  • Fax: 785-890-6077
Mailing address:
  • Phone: 785-890-6075
  • Fax: 785-890-6077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-01575
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: