Healthcare Provider Details

I. General information

NPI: 1386846707
Provider Name (Legal Business Name): AGNES A ENRICO-SIMON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 JACKSON AVE
PT PLEASANT WV
25550-2042
US

IV. Provider business mailing address

2415 JACKSON AVE
PT PLEASANT WV
25550-2042
US

V. Phone/Fax

Practice location:
  • Phone: 304-675-6090
  • Fax: 304-675-5893
Mailing address:
  • Phone: 304-675-6090
  • Fax: 304-675-5893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: AGNES A ENRICO-SIMON
Title or Position: PHYSICIAN
Credential: MD
Phone: 304-675-6817