Provider Demographics
NPI:1558308122
Name:SMITH, JEFFREY M (RPA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-0091
Mailing Address - Country:US
Mailing Address - Phone:315-782-4207
Mailing Address - Fax:315-782-8699
Practice Address - Street 1:727 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4031
Practice Address - Country:US
Practice Address - Phone:315-785-7009
Practice Address - Fax:315-785-7566
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA1374Medicare PIN