Provider Demographics
NPI:1023335627
Name:SMITH, SHAWN CHRISTOPHER (PA-C)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:CHRISTOPHER
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 S. DOBSON ROAD
Mailing Address - Street 2:SUITE 501
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202
Mailing Address - Country:US
Mailing Address - Phone:602-404-3700
Mailing Address - Fax:602-404-3703
Practice Address - Street 1:1432 S. DOBSON ROAD
Practice Address - Street 2:SUITE 501
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202
Practice Address - Country:US
Practice Address - Phone:602-404-3700
Practice Address - Fax:602-404-3703
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4577363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ138481OtherPTAN
AZZ145332Medicare PIN