Provider Demographics
NPI:1366848137
Name:SMITH, MICHAEL (MSPAS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSPAS
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:JAMES
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSAPS
Mailing Address - Street 1:1819 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1923 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-6520
Practice Address - Country:US
Practice Address - Phone:918-748-7585
Practice Address - Fax:918-748-7539
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAPA2412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant