Provider Demographics
NPI:1588650501
Name:SMITH, MARA S (PA-C)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:S
Other - Last Name:YORK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:603-610-8092
Mailing Address - Fax:603-610-8096
Practice Address - Street 1:121 CORPORATE DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801
Practice Address - Country:US
Practice Address - Phone:603-610-8092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0392P363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3083043Medicaid
NHP00835272OtherRAILROAD MEDICARE
NHP00835272OtherRAILROAD MEDICARE
NH3083043Medicaid
NH30331525Medicaid
NHP34841Medicare UPIN
NH3083043Medicaid