Provider Demographics
NPI:1609199876
Name:SMITH, SHANE O (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:O
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:16840 BUCCANEER LN STE 202
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2570
Mailing Address - Country:US
Mailing Address - Phone:281-991-2200
Mailing Address - Fax:281-991-7700
Practice Address - Street 1:1104 RAYFORD RD STE 500
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-2621
Practice Address - Country:US
Practice Address - Phone:281-825-3265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA08487363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant