Provider Demographics
NPI:1629042932
Name:SMITH, CHRISTOPHER D (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1219
Mailing Address - Country:US
Mailing Address - Phone:860-440-0688
Mailing Address - Fax:860-437-0318
Practice Address - Street 1:196 PARKWAY S
Practice Address - Street 2:SUITE 201
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1219
Practice Address - Country:US
Practice Address - Phone:860-440-0688
Practice Address - Fax:860-437-0318
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001562363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970001972Medicare ID - Type Unspecified