Provider Demographics
NPI:1003157660
Name:SMITH, RALPH HENRY JR (PA)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:HENRY
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 61 BOX 30
Mailing Address - Street 2:
Mailing Address - City:TEEC NOS POS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514-9600
Mailing Address - Country:US
Mailing Address - Phone:928-656-5000
Mailing Address - Fax:
Practice Address - Street 1:US HWY 160 & NAVAJO ROUTE 35- RED MESA
Practice Address - Street 2:
Practice Address - City:TEECNOSPOS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5431363A00000X
NM98-PA20363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant