Healthcare Provider Details

I. General information

NPI: 1861426124
Provider Name (Legal Business Name): SIMON O CANO JR. P. A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S COULTER ST
AMARILLO TX
79106-1836
US

IV. Provider business mailing address

1100 S COULTER ST
AMARILLO TX
79106-1836
US

V. Phone/Fax

Practice location:
  • Phone: 806-468-9700
  • Fax: 806-468-9771
Mailing address:
  • Phone: 806-468-9700
  • Fax: 806-468-9771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2901
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: