Provider Demographics
NPI:1437677945
Name:SMOUSE, ALISSA K (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:K
Last Name:SMOUSE
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 1:333 MERCY AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-8319
Mailing Address - Country:US
Mailing Address - Phone:209-564-5130
Mailing Address - Fax:
Practice Address - Street 1:333 MERCY AVE
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-8319
Practice Address - Country:US
Practice Address - Phone:855-548-7719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant