Provider Demographics
NPI:1083664981
Name:SMITH, ANTHONY NELSON (PA)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:NELSON
Last Name:SMITH
Suffix:
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:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071
Mailing Address - Country:US
Mailing Address - Phone:971-983-5260
Mailing Address - Fax:971-983-5326
Practice Address - Street 1:450 WELCH STREET
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381
Practice Address - Country:US
Practice Address - Phone:503-873-8740
Practice Address - Fax:503-873-2470
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005000363AS0400X
ORPA176235363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8452211Medicaid
WAQ67315Medicare UPIN
WA8859543Medicare PIN