Provider Demographics
NPI:1558875013
Name:SMUTZ, LAURA T (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:T
Last Name:SMUTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:J
Other - Last Name:TIERNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3521 GRANADA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-4125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:577 THIRD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5619
Practice Address - Country:US
Practice Address - Phone:858-909-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1143086363A00000X
PAMA059617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103446545Medicaid