Provider Demographics
NPI:1053780940
Name:SIMON, BLAIRE MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:BLAIRE
Middle Name:MICHELLE
Last Name:SIMON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BLAIRE
Other - Middle Name:MICHELLE
Other - Last Name:BOYDSTUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3706 CROW VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-4203
Mailing Address - Country:US
Mailing Address - Phone:281-380-5158
Mailing Address - Fax:
Practice Address - Street 1:22001 SOUTHWEST FWY STE 200
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-7002
Practice Address - Country:US
Practice Address - Phone:832-595-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10135363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA10135OtherPA LICENSE