Provider Demographics
NPI:1801015037
Name:SMITH, STEPHEN GLEN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:GLEN
Last Name:SMITH
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:1462 SE GRIFFIN TER
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5414
Mailing Address - Country:US
Mailing Address - Phone:772-337-0981
Mailing Address - Fax:772-335-9941
Practice Address - Street 1:6501 S OCEAN DR
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-2041
Practice Address - Country:US
Practice Address - Phone:772-468-4206
Practice Address - Fax:772-468-4270
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
FLPA9101253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant