Provider Demographics
NPI:1154073971
Name:SMITH, ADDISON (PA-C)
Entity Type:Individual
Prefix:
First Name:ADDISON
Middle Name:
Last Name:SMITH
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 1:55 SARATOGA CIR S
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3339
Mailing Address - Country:US
Mailing Address - Phone:561-400-8715
Mailing Address - Fax:
Practice Address - Street 1:55 SARATOGA CIR S
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-3339
Practice Address - Country:US
Practice Address - Phone:561-400-8715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9115534363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant