Provider Demographics
NPI:1154327161
Name:SMITH, MILAGROS C (PA)
Entity Type:Individual
Prefix:
First Name:MILAGROS
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MILAGROS
Other - Middle Name:C
Other - Last Name:VERGARAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-0091
Mailing Address - Country:US
Mailing Address - Phone:315-782-4207
Mailing Address - Fax:315-782-8699
Practice Address - Street 1:727 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4031
Practice Address - Country:US
Practice Address - Phone:315-785-7009
Practice Address - Fax:315-785-7566
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005734-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA1372Medicare PIN
S44047Medicare UPIN