Provider Demographics
NPI:1306833702
Name:SMITH, KATHLEEN DAWN (PA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 S NATIONAL AVE
Mailing Address - Street 2:URGENT CARE
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7304
Mailing Address - Country:US
Mailing Address - Phone:417-888-5666
Mailing Address - Fax:417-890-4174
Practice Address - Street 1:2321 S. NATIONAL
Practice Address - Street 2:SMITH GLYNN CALLAWAY URGENT CARE
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-888-5666
Practice Address - Fax:417-890-4174
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA878363A00000X
MO2008004931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
431560263OtherTRICARE WEST
P00653964OtherRAILROAD MEDICARE
431560263OtherTRICARE WEST