Provider Demographics
NPI:1336698851
Name:SMITH, MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5880 S HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-9447
Mailing Address - Country:US
Mailing Address - Phone:928-402-1175
Mailing Address - Fax:928-425-7903
Practice Address - Street 1:5880 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-9447
Practice Address - Country:US
Practice Address - Phone:503-353-5573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6544363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant