Provider Demographics
NPI:1336530112
Name:SMITH, NIKEDA (PA-C)
Entity Type:Individual
Prefix:
First Name:NIKEDA
Middle Name:
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 1:720 W OAK ST STE 303
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4992
Mailing Address - Country:US
Mailing Address - Phone:407-520-3947
Mailing Address - Fax:
Practice Address - Street 1:720 W OAK ST STE 303
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4992
Practice Address - Country:US
Practice Address - Phone:407-520-3947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-14
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
9108550363AS0400X
FLPA9108550207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1336530112Medicaid