Provider Demographics
NPI:1952730970
Name:SMITH, SHONTAE (PA)
Entity Type:Individual
Prefix:
First Name:SHONTAE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5615 YORK RD
Mailing Address - Street 2:
Mailing Address - City:NEW OXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:17350-9553
Mailing Address - Country:US
Mailing Address - Phone:717-624-1337
Mailing Address - Fax:717-624-1795
Practice Address - Street 1:875 MANTUA PIKE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096
Practice Address - Country:US
Practice Address - Phone:856-384-5949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant