Provider Demographics
NPI:1194818658
Name:SMITH, KELLY M (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-0304
Mailing Address - Country:US
Mailing Address - Phone:518-854-3821
Mailing Address - Fax:518-854-3224
Practice Address - Street 1:213 MAIN STREET
Practice Address - Street 2:SALEM FAMILY HEALTH CENTER
Practice Address - City:SALEM
Practice Address - State:NY
Practice Address - Zip Code:12865
Practice Address - Country:US
Practice Address - Phone:518-854-3821
Practice Address - Fax:518-854-3224
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY003117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01599751Medicaid
NY01599751Medicaid
S31401Medicare UPIN