Provider Demographics
NPI:1639448798
Name:SMITH, STEPHEN MAX (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MAX
Last Name:SMITH
Suffix:
Gender:M
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:PO BOX 980
Mailing Address - Street 2:
Mailing Address - City:CHALLIS
Mailing Address - State:ID
Mailing Address - Zip Code:83226-0980
Mailing Address - Country:US
Mailing Address - Phone:208-879-4351
Mailing Address - Fax:208-879-5216
Practice Address - Street 1:611 CLINIC ROAD
Practice Address - Street 2:
Practice Address - City:CHALLIS
Practice Address - State:ID
Practice Address - Zip Code:83226
Practice Address - Country:US
Practice Address - Phone:208-879-4351
Practice Address - Fax:208-879-5216
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant