Provider Demographics
NPI:1962472506
Name:SMARRA, MARY BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:SMARRA
Suffix:
Gender:F
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 1:605 N WESTOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-2188
Mailing Address - Country:US
Mailing Address - Phone:520-625-6600
Mailing Address - Fax:520-625-8467
Practice Address - Street 1:605 N WESTOVER BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-2188
Practice Address - Country:US
Practice Address - Phone:520-625-6600
Practice Address - Fax:520-625-8467
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003457L363A00000X
AZ3714363AM0700X
GA7797363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ28852Medicare UPIN
PA085451Medicare ID - Type Unspecified