Provider Demographics
NPI:1912548421
Name:SMITH, TAYLOR DREW (MSPH, PA-C)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:DREW
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSPH, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 LOST RIVER RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5724
Mailing Address - Country:US
Mailing Address - Phone:208-821-2402
Mailing Address - Fax:
Practice Address - Street 1:187 E 13TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5305
Practice Address - Country:US
Practice Address - Phone:208-497-0500
Practice Address - Fax:208-497-0198
Is Sole Proprietor?:No
Enumeration Date:2019-10-06
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1774363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant