Provider Demographics
NPI:1073673521
Name:SMITH, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:SUE
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:620 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WAPATO
Mailing Address - State:WA
Mailing Address - Zip Code:98951-1108
Mailing Address - Country:US
Mailing Address - Phone:509-877-4111
Mailing Address - Fax:509-877-7349
Practice Address - Street 1:620 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WAPATO
Practice Address - State:WA
Practice Address - Zip Code:98951-1108
Practice Address - Country:US
Practice Address - Phone:509-877-4111
Practice Address - Fax:509-877-7349
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10009097208000000X
OH52698208000000X
WAMD60964858208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
A17197Medicare UPIN