Provider Demographics
NPI:1619090131
Name:SMALLEY, CHRISTOPHER D (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:D
Last Name:SMALLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-8802
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1050 REID PARKWAY
Practice Address - Street 2:SUITE 220
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1161
Practice Address - Country:US
Practice Address - Phone:765-962-8551
Practice Address - Fax:765-962-2591
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10000676A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000683307OtherANTHEM
INM400037685Medicare PIN