Provider Demographics
NPI:1801043591
Name:SMITH, RONALD C (PA-C, MMSC)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11782 SW BARNES RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5914
Mailing Address - Country:US
Mailing Address - Phone:503-214-5200
Mailing Address - Fax:503-906-6613
Practice Address - Street 1:11782 SW BARNES RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5914
Practice Address - Country:US
Practice Address - Phone:503-214-5200
Practice Address - Fax:503-906-6613
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00582363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1801043591OtherNPI