Provider Demographics
NPI:1316199714
Name:SMITH, ROBERTA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MARIE
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 1:3801 KATELLA AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 KATELLA AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3338
Practice Address - Country:US
Practice Address - Phone:562-594-9546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant