Provider Demographics
NPI:1710217393
Name:SMOCK, JOHN P (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:SMOCK
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 669
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2329
Mailing Address - Country:US
Mailing Address - Phone:928-247-6516
Mailing Address - Fax:
Practice Address - Street 1:11274 S FORTUNA RD STE I4
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-7849
Practice Address - Country:US
Practice Address - Phone:928-345-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant