Provider Demographics
NPI:1093735367
Name:SMITH, ROSALINDE OLIVIA (PA-C)
Entity Type:Individual
Prefix:
First Name:ROSALINDE
Middle Name:OLIVIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ROSALINDE
Other - Middle Name:OLIVIA
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4798 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:DALE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:22193-4924
Mailing Address - Country:US
Mailing Address - Phone:703-878-7595
Mailing Address - Fax:
Practice Address - Street 1:8350 RICHMOND HWY STE 301
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22309-2344
Practice Address - Country:US
Practice Address - Phone:703-704-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840448363AM0700X
MDC0000343363AM0700X
DCPA52363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S09103Medicare UPIN
VA016864E14Medicare ID - Type Unspecified