Provider Demographics
NPI:1235186578
Name:ROBERTS-SMITH, TINA SUE-MARIE (MPAS,PA-C)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:SUE-MARIE
Last Name:ROBERTS-SMITH
Suffix:
Gender:F
Credentials:MPAS,PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3260
Mailing Address - Country:US
Mailing Address - Phone:386-738-0322
Mailing Address - Fax:
Practice Address - Street 1:600 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3260
Practice Address - Country:US
Practice Address - Phone:386-738-0322
Practice Address - Fax:386-738-0628
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3744363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP16080Medicare UPIN
FLE4698Medicare ID - Type Unspecified