Basic Information
| Provider Information | |||||||||
| NPI: | 1013301340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMKINS | ||||||||
| FirstName: | TYRELL | ||||||||
| MiddleName: | JONATHAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O., PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3160 FOLSOM BLVD STE 2100 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167343588 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3160 FOLSOM BLVD STE 2100 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167343588 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2015 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 20A15185 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | DO192558 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | DO192558 | 01 | OR | OREGON MEDICAL LICENSE | OTHER | 20A15185 | 01 | CA | CALIFORNIA MEDICAL LICENSE | OTHER |