Provider Demographics
NPI:1407392822
Name:SMITH, MITCHELL
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3081 COUNTY ROAD 1208
Mailing Address - Street 2:
Mailing Address - City:MAUD
Mailing Address - State:TX
Mailing Address - Zip Code:75567-4524
Mailing Address - Country:US
Mailing Address - Phone:903-733-1513
Mailing Address - Fax:
Practice Address - Street 1:2001 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2338
Practice Address - Country:US
Practice Address - Phone:903-577-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132958367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered