Provider Demographics
NPI:1477370278
Name:SMITH, PAEN
Entity type:Individual
Prefix:
First Name:PAEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-8525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5210 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-8525
Practice Address - Country:US
Practice Address - Phone:520-800-6043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235952176B00000X
CA95008935363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No176B00000XOther Service ProvidersMidwife