Provider Demographics
NPI:1972836609
Name:SMITH, KRISTA M (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:M
Last Name:SMITH
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 1:2655 RIDGEWAY AVE
Mailing Address - Street 2:SUITE 440
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4296
Mailing Address - Country:US
Mailing Address - Phone:585-723-7705
Mailing Address - Fax:585-368-3219
Practice Address - Street 1:2655 RIDGEWAY AVE
Practice Address - Street 2:SUITE 440
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4296
Practice Address - Country:US
Practice Address - Phone:585-723-7705
Practice Address - Fax:585-368-3219
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020496363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04738863Medicaid
NYJ400378716/GRP70008AMedicare PIN
NYJ400378715/GRPBA0017Medicare PIN