Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 37092 | WI |
N | 207QA0505X | Family Doctor - Adult Medicine | 4301089159 | MI |
NPI | 1336189075 |
---|---|
Provider Name | Jon L Simmons |
First Address | Green Bay, WI 54305-1866 |
Second Address | Marinette, WI 54143-3834 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2006 |
Last Update Date | 31/05/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
32167300 | (05) | WI |
4957216 | (05) | MI |
G15420 | (02) |