Provider Demographics
NPI:1578808556
Name:SMITH, NIKEDA MARIE (PA)
Entity Type:Individual
Prefix:MRS
First Name:NIKEDA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:HSC, LEVEL 4, ROOM 050
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8350
Practice Address - Country:US
Practice Address - Phone:631-445-2478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016219363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant