Provider Demographics
NPI:1275516825
Name:SMOAK, DENNIS JASON (PA)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:JASON
Last Name:SMOAK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 W MAIN ST STE 1001
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-6404
Mailing Address - Country:US
Mailing Address - Phone:334-794-2825
Mailing Address - Fax:334-793-5050
Practice Address - Street 1:2431 W MAIN ST STE 1001
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-6404
Practice Address - Country:US
Practice Address - Phone:334-794-2825
Practice Address - Fax:344-793-5050
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-31347OtherBCBS-1108 ROSS CLARK
AL515-31348OtherBCBS-4370 W MAIN ST
AL515-31346OtherBCBS-1900 FAIRVIEW
AL515-31349OtherBCBS-400 N EDWARDS