Provider Demographics
NPI:1477980472
Name:SMITH, GARY SPENCER (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:SPENCER
Last Name:SMITH
Suffix:
Gender:M
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 1:1300 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4646
Mailing Address - Country:US
Mailing Address - Phone:850-216-0100
Mailing Address - Fax:850-216-0112
Practice Address - Street 1:1300 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4646
Practice Address - Country:US
Practice Address - Phone:850-216-0100
Practice Address - Fax:850-216-0112
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107568363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant