Provider Demographics
NPI:1679568356
Name:SMITH, JEANNA REID (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JEANNA
Middle Name:REID
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 1:1671 N MARLBOROUGH LOOP
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-8713
Mailing Address - Country:US
Mailing Address - Phone:352-563-1154
Mailing Address - Fax:
Practice Address - Street 1:6254 W CORPORATE OAKS DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-8723
Practice Address - Country:US
Practice Address - Phone:352-795-3232
Practice Address - Fax:352-795-3350
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9101103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP06235Medicare UPIN
FLE4107YMedicare ID - Type Unspecified