Provider Demographics
NPI:1659309557
Name:SMITH, ANNTARA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANNTARA
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 1:1702 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5121
Mailing Address - Country:US
Mailing Address - Phone:208-957-7400
Mailing Address - Fax:
Practice Address - Street 1:1702 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5121
Practice Address - Country:US
Practice Address - Phone:208-957-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA482363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807782300Medicaid
Q07703Medicare UPIN
ID16656843Medicare PIN
ID16656842Medicare PIN
ID16656841Medicare PIN
ID806781000Medicaid