Provider Demographics
NPI:1275648834
Name:SMITH, MARYELLEN WARRO (PA)
Entity Type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:WARRO
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARYELLEN
Other - Middle Name:
Other - Last Name:WARRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1905 S DONNYBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4236
Mailing Address - Country:US
Mailing Address - Phone:903-597-3140
Mailing Address - Fax:903-595-5693
Practice Address - Street 1:5414 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1335
Practice Address - Country:US
Practice Address - Phone:903-581-1601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04930363A00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-001OtherTRICARE
TX8544NDOtherBCBS
TX75-1976930-005OtherTRICARE
TX75-2616977-028OtherTRICARE
TX8547NDOtherBCBS
TX337319301Medicaid
TX75-0818167-048OtherTRICARE
TX75-0818167-044OtherTRICARE
TX75-0818167-015OtherTRICARE
TX75-0818167-022OtherTRICARE
TX8545NDOtherBCBS
TX337319303Medicaid
TX75-2616977-002OtherTRICARE
TX8546NDOtherBCBS
TX337319302Medicaid
TX337319304Medicaid
TX75-0818167-022OtherTRICARE
TX337319304Medicaid
TX337319302Medicaid
TXP01352808Medicare Oscar/Certification
TX8546NDOtherBCBS
TX337319301Medicaid
TX75-0818167-015OtherTRICARE
TX75-1976930-005OtherTRICARE
TX8544NDOtherBCBS