Healthcare Provider Details

I. General information

NPI: 1508955683
Provider Name (Legal Business Name): MARK ANTHONY SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 IRVING ST NW THE VA MEDICAL CENTER
WASHINGTON DC
20422
US

IV. Provider business mailing address

12871 MURPHY GROVE TER
CLARKSBURG MD
20871-4318
US

V. Phone/Fax

Practice location:
  • Phone: 202-745-8295
  • Fax:
Mailing address:
  • Phone: 301-540-7190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC 02712
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: