Provider Demographics
NPI:1841290848
Name:SMITH, NANCY L (PA-C)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:L
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:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3310 LIVE OAK ST
Practice Address - Street 2:YOUTH & FAMILY CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6153
Practice Address - Country:US
Practice Address - Phone:214-266-1257
Practice Address - Fax:214-266-1258
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179692202Medicaid
TX179692203Medicaid
TX8M7900OtherBLUE CROSS BLUE SHIELD
TX179692204Medicaid
TX179692201Medicaid
82N836Medicare PIN
TX179692202Medicaid