Provider Demographics
NPI:1629451380
Name:SMITH, MARY EVELYN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY EVELYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 SAN PASQUAL ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-5157
Mailing Address - Country:US
Mailing Address - Phone:626-840-1120
Mailing Address - Fax:
Practice Address - Street 1:2080 SAN PASQUAL ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-5157
Practice Address - Country:US
Practice Address - Phone:626-840-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant