Provider Demographics
NPI:1285837799
Name:CODERELLIS, SIMONE PATRICE (P A)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:PATRICE
Last Name:CODERELLIS
Suffix:
Gender:F
Credentials:P A
Other - Prefix:
Other - First Name:SIMONE
Other - Middle Name:PATRICE
Other - Last Name:MUSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:P A
Mailing Address - Street 1:7305 PEARLY HEATH RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-5640
Mailing Address - Country:US
Mailing Address - Phone:404-275-6797
Mailing Address - Fax:
Practice Address - Street 1:5799 STETSON HILLS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-4223
Practice Address - Country:US
Practice Address - Phone:719-471-2273
Practice Address - Fax:719-325-8971
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0008220363AM0700X
CO0008220363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical