Basic Information
| Provider Information | |||||||||
| NPI: | 1386846707 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AGNES A ENRICO-SIMON, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2415 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255502042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046756090 | ||||||||
| FaxNumber: | 3046755893 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255502042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046756090 | ||||||||
| FaxNumber: | 3046755893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ENRICO-SIMON | ||||||||
| AuthorizedOfficialFirstName: | AGNES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3046756817 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3002914000 | 05 | WV | MEDICAID |