Provider Demographics
NPI:1588626477
Name:SMITH, PAMELA S (ANP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:S
Other - Last Name:TYLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:PO BOX 84658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX236425363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0007981-02Medicaid
TX8N9151OtherBLUE SHIELD
TXP00269386OtherRR/MEDICARE
TX0007981-02Medicaid
TX8N9151OtherBLUE SHIELD