Provider Demographics
NPI:1821072380
Name:SMITH, KELLY ANN (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:VOLMERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 DAIRY ASHFORD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-3017
Mailing Address - Country:US
Mailing Address - Phone:713-407-3000
Mailing Address - Fax:713-461-3476
Practice Address - Street 1:16001 PARK TEN PL STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-7885
Practice Address - Country:US
Practice Address - Phone:713-407-3000
Practice Address - Fax:713-461-3476
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00311207R00000X
TX1016844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS55173Medicare UPIN
TXTXB114867Medicare PIN