Healthcare Provider Details

I. General information

NPI: 1497847859
Provider Name (Legal Business Name): JEFFREY KEITH SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N STATE ST BLDG B, SUITE D & E
HEMET CA
92543-1485
US

IV. Provider business mailing address

27699 JEFFERSON AVE SUITE 300
TEMECULA CA
92590-2661
US

V. Phone/Fax

Practice location:
  • Phone: 951-765-1777
  • Fax: 951-765-1772
Mailing address:
  • Phone: 951-252-8588
  • Fax: 951-252-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: