Healthcare Provider Details

I. General information

NPI: 1992983001
Provider Name (Legal Business Name): TONYA LANETT SMITH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1552 COFFEE RD STE 200
MODESTO CA
95355-3122
US

IV. Provider business mailing address

PO BOX 1750
MANTECA CA
95336-1153
US

V. Phone/Fax

Practice location:
  • Phone: 209-248-7168
  • Fax: 209-846-9641
Mailing address:
  • Phone: 209-665-8566
  • Fax: 209-846-9641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA19549
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: