Provider Demographics
NPI:1457655359
Name:SMITH, AMY (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:VANDEGRIFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 8500-4081
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-4081
Mailing Address - Country:US
Mailing Address - Phone:215-856-1010
Mailing Address - Fax:215-856-1141
Practice Address - Street 1:1648 HUNTINGDON PIKE
Practice Address - Street 2:
Practice Address - City:MEADOWBROOK
Practice Address - State:PA
Practice Address - Zip Code:19046-8001
Practice Address - Country:US
Practice Address - Phone:215-938-2749
Practice Address - Fax:215-938-3829
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000733363AM0700X
PAMA055636363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA255152FDDMedicare PIN