Provider Demographics
NPI:1376321968
Name:SMITH, MANDALYN (PA-C)
Entity Type:Individual
Prefix:
First Name:MANDALYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MANDALYN
Other - Middle Name:
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:155 N 575 E
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-3168
Mailing Address - Country:US
Mailing Address - Phone:385-529-8298
Mailing Address - Fax:
Practice Address - Street 1:2002 HOLCOMBE BLVD # 110
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4211
Practice Address - Country:US
Practice Address - Phone:713-791-7375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant