Provider Demographics
NPI:1952324246
Name:SMITH-WHITEEAGLE, TONI (PA)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:
Last Name:SMITH-WHITEEAGLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TONI
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5005 LIVE OAK ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402
Mailing Address - Country:US
Mailing Address - Phone:903-455-3500
Mailing Address - Fax:903-455-3509
Practice Address - Street 1:5005 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402
Practice Address - Country:US
Practice Address - Phone:903-455-3500
Practice Address - Fax:903-455-3509
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01198363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84N977Medicare ID - Type Unspecified
P05950Medicare UPIN
84N977Medicare Oscar/Certification
TXP05950Medicare UPIN