Provider Demographics
NPI:1760590541
Name:SMITH, MICHELE G (PA)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:G
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MICHELE
Other - Middle Name:M
Other - Last Name:GUITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:244 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2496
Mailing Address - Country:US
Mailing Address - Phone:207-775-3446
Mailing Address - Fax:207-879-1646
Practice Address - Street 1:244 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2496
Practice Address - Country:US
Practice Address - Phone:207-775-3446
Practice Address - Fax:207-879-1646
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA637363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEAP0604Medicare ID - Type Unspecified