Provider Demographics
NPI:1205867116
Name:SMITH, JAMES ERNEST (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ERNEST
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 1:5653 S HIGHWAY 95 STE A
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6069
Mailing Address - Country:US
Mailing Address - Phone:928-768-2558
Mailing Address - Fax:928-299-5099
Practice Address - Street 1:3650 S POINTE CIR STE 101
Practice Address - Street 2:
Practice Address - City:LAUGHLIN
Practice Address - State:NV
Practice Address - Zip Code:89029-0422
Practice Address - Country:US
Practice Address - Phone:702-299-4252
Practice Address - Fax:702-299-4251
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTP7937363A00000X, 363AM0700X
CAPA16559363AM0700X
NV2653363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP90360Medicare UPIN