Basic Information
| Provider Information | |||||||||
| NPI: | 1942677919 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SIMON | ||||||||
| FirstName: | SHIJU | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | AA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5307 MAIN ST | ||||||||
| Address2: | STE 102 | ||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346522513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278451736 | ||||||||
| FaxNumber: | 7278490759 | ||||||||
| Practice Location | |||||||||
| Address1: | 9330 STATE ROAD 54 | ||||||||
| Address2: | MEDICAL CENTER TRINITY | ||||||||
| City: | TRINITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346551808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278481733 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2015 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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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 | 367H00000X | 9220 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | AA287 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 015893200 | 05 | FL | MEDICAID |