Provider Demographics
NPI:1811945629
Name:SMITH, MICHEAL (PA)
Entity type:Individual
Prefix:MR
First Name:MICHEAL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 TIMBERLAKE WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-5401
Mailing Address - Country:US
Mailing Address - Phone:916-688-5837
Mailing Address - Fax:916-689-6620
Practice Address - Street 1:8110 TIMBERLAKE WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5401
Practice Address - Country:US
Practice Address - Phone:916-688-5837
Practice Address - Fax:916-689-6620
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA14393363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP86059Medicare UPIN