Provider Demographics
NPI:1255367074
Name:SMUCKER, KRISTIN B (PA)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:B
Last Name:SMUCKER
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:125 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2665
Mailing Address - Country:US
Mailing Address - Phone:304-624-7200
Mailing Address - Fax:304-624-0026
Practice Address - Street 1:120 MEDICAL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9012
Practice Address - Country:US
Practice Address - Phone:304-624-7200
Practice Address - Fax:304-624-0026
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2015-01-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV00806363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPA18772Medicare PIN
WVP61030Medicare UPIN