Healthcare Provider Details

I. General information

NPI: 1003910670
Provider Name (Legal Business Name): AGNES A ENRICO-SIMON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 02/19/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 JEFFERSON AVE
PT PLEASANT WV
25550-1528
US

IV. Provider business mailing address

2420 JEFFERSON AVE
PT PLEASANT WV
25550-1528
US

V. Phone/Fax

Practice location:
  • Phone: 304-675-6817
  • Fax: 304-675-5893
Mailing address:
  • Phone: 304-675-6817
  • Fax: 304-675-5893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20514
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: