Provider Demographics
NPI:1477765931
Name:SMITH, ROBERT J (PA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
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 1:1405 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4557
Mailing Address - Country:US
Mailing Address - Phone:707-546-1922
Mailing Address - Fax:707-546-1897
Practice Address - Street 1:1405 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4557
Practice Address - Country:US
Practice Address - Phone:707-546-1922
Practice Address - Fax:707-546-1897
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20267363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20267Medicaid
CA0PA202670OtherCIGNA DME
CAPA20267OtherLICENSE NUMBER
CA0PA202670OtherCIGNA DME
CAPA20267OtherLICENSE NUMBER