Provider Demographics
NPI:1083738686
Name:SMALLWOOD, DEBORAH V (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:V
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5609 INDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3238
Mailing Address - Country:US
Mailing Address - Phone:408-224-4383
Mailing Address - Fax:
Practice Address - Street 1:5609 INDIAN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-3238
Practice Address - Country:US
Practice Address - Phone:408-224-4383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA12127OtherPHYSICIAN ASST. LICENSE
CAAN259ZMedicare PIN
CAAX558YMedicare PIN