Provider Demographics
NPI:1578552857
Name:SMITH, TRUDY LENNETTE (PA)
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:LENNETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRUDY
Other - Middle Name:
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 2435
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:TX
Mailing Address - Zip Code:76430-8020
Mailing Address - Country:US
Mailing Address - Phone:325-893-4010
Mailing Address - Fax:325-893-4042
Practice Address - Street 1:1712 NORTH ACCESS ROAD
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:TX
Practice Address - Zip Code:79510
Practice Address - Country:US
Practice Address - Phone:325-893-4010
Practice Address - Fax:325-893-4042
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01805363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S63836Medicare UPIN
TX87N458Medicare PIN
TX87N458Medicare ID - Type Unspecified