Provider Demographics
NPI:1477269207
Name:SMITH, STEPHEN (PA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 MEDICAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9104
Mailing Address - Country:US
Mailing Address - Phone:914-275-7208
Mailing Address - Fax:
Practice Address - Street 1:9330 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9104
Practice Address - Country:US
Practice Address - Phone:865-985-7129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant