Provider Demographics
NPI:1689680779
Name:SMITH, ROXANNE (PAC)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOLLYWOOD AVE
Mailing Address - Street 2:HILLSIDE FAMILY PRACTICE
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07205-2409
Mailing Address - Country:US
Mailing Address - Phone:908-353-7949
Mailing Address - Fax:908-353-8374
Practice Address - Street 1:100 HOLLYWOOD AVE
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205-2409
Practice Address - Country:US
Practice Address - Phone:908-353-7949
Practice Address - Fax:908-353-8374
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00086300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P89583Medicare UPIN
069821Medicare ID - Type Unspecified