Provider Demographics
NPI:1508508409
Name:SMITH, MCKOTAH BRICE (PA)
Entity Type:Individual
Prefix:
First Name:MCKOTAH
Middle Name:BRICE
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 1:3462 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:HEALDTON
Mailing Address - State:OK
Mailing Address - Zip Code:73438-6124
Mailing Address - Country:US
Mailing Address - Phone:580-229-0701
Mailing Address - Fax:
Practice Address - Street 1:3462 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:HEALDTON
Practice Address - State:OK
Practice Address - Zip Code:73438-6124
Practice Address - Country:US
Practice Address - Phone:580-229-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant