Provider Demographics
NPI:1669460986
Name:SMITH, BROCK LEWIS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BROCK
Middle Name:LEWIS
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 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7469
Mailing Address - Fax:
Practice Address - Street 1:3251 N MCMULLEN BOOTH RD STE 301
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2022
Practice Address - Country:US
Practice Address - Phone:727-669-5300
Practice Address - Fax:727-669-5366
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02632363AS0400X
FLPA9117281363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical