Provider Demographics
NPI:1629321021
Name:SMITH, MARK SAMUEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SAMUEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:FOURTH FLOOR
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7659
Mailing Address - Country:US
Mailing Address - Phone:276-258-4050
Mailing Address - Fax:276-258-4056
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7659
Practice Address - Country:US
Practice Address - Phone:276-258-4050
Practice Address - Fax:276-258-4056
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2017-02-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN2210363A00000X
VA0110004485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01334893OtherRR MEDICARE
TNQ000164Medicaid
VA1629321021Medicaid
TN103I979095Medicare PIN
VA1629321021Medicaid