MEDICARE: MS. CAROLYN A SMITH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	2158	AZ

General Provider Information

NPI Number	:	1558462614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROLYN A SMITH PA-C

Provider Business Mailing Address
First Line	:	2034 E SOUTHERN AVE
Second Line	:	SUITE O
City	:	TEMPE
State	:	AZ
Zip	:	85282-7522
Country	:	US
Telephone Number	:	480-777-0077
Fax Number	:	480-731-4741

Provider Business Practice Location Address
First Line	:	2034 E SOUTHERN AVE
Second Line	:	SUITE O
City	:	TEMPE
State	:	AZ
Zip	:	85282-7522
Country	:	US
Telephone Number	:	480-777-0077
Fax Number	:	480-731-4741

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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