Provider Demographics
NPI:1205502200
Name:SMITH, ZACHARY JOSEPH (PA)
Entity type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:JOSEPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 STATE ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:AKWESASNE
Mailing Address - State:NY
Mailing Address - Zip Code:13655-3109
Mailing Address - Country:US
Mailing Address - Phone:518-358-3141
Mailing Address - Fax:
Practice Address - Street 1:412 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:AKWESASNE
Practice Address - State:NY
Practice Address - Zip Code:13655-3109
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant