Provider Demographics
NPI:1821643024
Name:SMITH, PHILLIP RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:RYAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 W BEEBE CAPPS EXPY
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4909
Mailing Address - Country:US
Mailing Address - Phone:501-278-2800
Mailing Address - Fax:
Practice Address - Street 1:2505 W BEEBE CAPPS EXPY
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4909
Practice Address - Country:US
Practice Address - Phone:501-278-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR261304795Medicaid