Basic Information
| Provider Information | |||||||||
| NPI: | 1851634653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMONS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1033 EDGEFIELD ST | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296463205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642273908 | ||||||||
| FaxNumber: | 8642272668 | ||||||||
| Practice Location | |||||||||
| Address1: | 1033 EDGEFIELD ST | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296463205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642273908 | ||||||||
| FaxNumber: | 8642272668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2013 | ||||||||
| LastUpdateDate: | 11/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TL1906 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1704PA | 05 | SC | MEDICAID |