Provider Demographics
NPI:1164584074
Name:SMITH, CAREN J (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAREN
Middle Name:J
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 1:765 S UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5093
Mailing Address - Country:US
Mailing Address - Phone:208-525-2600
Mailing Address - Fax:208-525-2611
Practice Address - Street 1:765 S UTAH AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-5093
Practice Address - Country:US
Practice Address - Phone:208-525-2600
Practice Address - Fax:208-525-2611
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID16681774OtherMEDICARE PTAN