Provider Demographics
NPI:1619128360
Name:SMITH, STACIE RENEE (PA)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:108 N SHACKLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2840
Mailing Address - Country:US
Mailing Address - Phone:501-712-2571
Mailing Address - Fax:501-404-7789
Practice Address - Street 1:108 N SHACKLEFORD RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2840
Practice Address - Country:US
Practice Address - Phone:501-712-2571
Practice Address - Fax:501-404-7789
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARPA-359363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56884P162Medicare PIN