=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255767588
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAD EDWARD SIMMONS PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2013
-----------------------------------------------------
Last Update Date | 09/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3330 MASONIC DR
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71301-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-981-6472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1464 600 CHRISTOPHER LN
-----------------------------------------------------
City | AMITE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70422-1464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-981-6472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA.200662
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------