Provider Demographics
NPI:1942856885
Name:MCDONALD-SMITH, ATHENA MARIE
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:MARIE
Last Name:MCDONALD-SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BEACH 123RD ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1828
Mailing Address - Country:US
Mailing Address - Phone:917-613-7318
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY STE 301
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-8156
Practice Address - Country:US
Practice Address - Phone:464-216-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024502363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty