Provider Demographics
NPI:1396414363
Name:SMITH, PAUL EDWARD (PT, DPT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-5504
Mailing Address - Country:US
Mailing Address - Phone:231-920-7760
Mailing Address - Fax:
Practice Address - Street 1:913 11TH ST SE STE 2
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9168
Practice Address - Country:US
Practice Address - Phone:541-347-4314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-12
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61251780225100000X
OR64256225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist