Provider Demographics
NPI:1720006349
Name:SMITH, SUSIE (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSIE
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 1:9097 W POST RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-2411
Mailing Address - Country:US
Mailing Address - Phone:702-430-5333
Mailing Address - Fax:702-430-5335
Practice Address - Street 1:9097 W POST RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-2411
Practice Address - Country:US
Practice Address - Phone:702-430-5333
Practice Address - Fax:702-430-5335
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDD038ZMedicare PIN