Provider Demographics
NPI:1942221585
Name:SMITH, MEGGAN MICHELLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MEGGAN
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MEGGAN
Other - Middle Name:MICHELLE
Other - Last Name:GOODWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:12855 N 40 DR STE 375
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8657
Mailing Address - Country:US
Mailing Address - Phone:314-567-6071
Mailing Address - Fax:
Practice Address - Street 1:12855 N 40 DR STE 350
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8669
Practice Address - Country:US
Practice Address - Phone:314-567-6071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04904363A00000X
IL085009473363A00000X
MO2021041128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO113620067OtherMEDICARE
TX8138NKOtherBCBS (MDACC)
TN8J2183OtherMEDICARE ID
TNQ75661Medicare UPIN
TX385224YKQH (MDACC)Medicare PIN