Provider Demographics
NPI:1649437997
Name:SMITH, RHONDA MICHELLE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MS
First Name:RHONDA
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:RHONDA
Other - Middle Name:MICHELLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:1300 MABLE AVENUE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355
Mailing Address - Country:US
Mailing Address - Phone:209-571-1992
Mailing Address - Fax:209-571-1994
Practice Address - Street 1:1300 MABLE AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:209-571-1992
Practice Address - Fax:209-571-1994
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14435363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14435OtherPA LICENSE
CAPA14435OtherPA LICENSE