Provider Demographics
NPI:1336110980
Name:SMITH, DELMAR WALLACE (PA)
Entity Type:Individual
Prefix:MR
First Name:DELMAR
Middle Name:WALLACE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2000 AMERICAN LEGION BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-3138
Mailing Address - Country:US
Mailing Address - Phone:208-587-1500
Mailing Address - Fax:208-587-3180
Practice Address - Street 1:2000 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3138
Practice Address - Country:US
Practice Address - Phone:208-587-1500
Practice Address - Fax:208-587-3180
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-265363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378052Medicare ID - Type UnspecifiedGROUP
ID1666124Medicare ID - Type UnspecifiedINDIVIDUAL
IDQ25302Medicare UPIN