Provider Demographics
NPI:1346693314
Name:SMITH, SAMANTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
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 1:128 JACKSON ST
Mailing Address - Street 2:PO BOX 527
Mailing Address - City:BROOKLYN
Mailing Address - State:IA
Mailing Address - Zip Code:52211-7711
Mailing Address - Country:US
Mailing Address - Phone:641-522-7221
Mailing Address - Fax:641-522-5816
Practice Address - Street 1:128 JACKSON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:IA
Practice Address - Zip Code:52211-7711
Practice Address - Country:US
Practice Address - Phone:641-522-7221
Practice Address - Fax:641-522-5816
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083680363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical