Provider Demographics
NPI:1003207499
Name:PAUL SMITH, KRISTIN MARIE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:PAUL SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MARIE
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5939 27TH TER N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-3307
Mailing Address - Country:US
Mailing Address - Phone:651-895-6930
Mailing Address - Fax:
Practice Address - Street 1:5939 27TH TER N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-3307
Practice Address - Country:US
Practice Address - Phone:651-895-6930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-07
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9108496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0143169Medicaid