Healthcare Provider Details

I. General information

NPI: 1205870813
Provider Name (Legal Business Name): MARRIE J SIMPSON P.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 CHERRY LN
ROBERTS WI
54023-9731
US

IV. Provider business mailing address

1100 BERGSLIEN ST
BALDWIN WI
54002-2600
US

V. Phone/Fax

Practice location:
  • Phone: 715-684-1111
  • Fax: 715-684-1119
Mailing address:
  • Phone: 715-684-1111
  • Fax: 715-684-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number695
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: