Provider Demographics
NPI:1790076586
Name:SMITH, ABBIE M (PA)
Entity Type:Individual
Prefix:
First Name:ABBIE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ABBIE
Other - Middle Name:M
Other - Last Name:MANGIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6866 W STONEGATE DR STE 100
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-8051
Practice Address - Country:US
Practice Address - Phone:317-768-6000
Practice Address - Fax:317-768-6015
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001293A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN068010142Medicare PIN
INM400051032Medicare PIN
IN264430281Medicare PIN