Provider Demographics
NPI:1083616080
Name:SMITH, PAUL A (ANP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:128 N ELLIS ST
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:TX
Practice Address - Zip Code:75570-2904
Practice Address - Country:US
Practice Address - Phone:903-628-1104
Practice Address - Fax:903-628-0104
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX506033363LF0000X
ARA01143363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S47255Medicare UPIN
TX86N981Medicare ID - Type Unspecified