Provider Demographics
NPI:1093751265
Name:SMITH, MICHAEL L (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
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 1:2010 BILL OWENS PKWY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-6210
Mailing Address - Country:US
Mailing Address - Phone:903-247-3400
Mailing Address - Fax:903-238-9183
Practice Address - Street 1:2010 BILL OWENS PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-6210
Practice Address - Country:US
Practice Address - Phone:903-247-3400
Practice Address - Fax:903-238-9183
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G6753Medicare PIN
TXP05306Medicare UPIN