Healthcare Provider Details

I. General information

NPI: 1275266694
Provider Name (Legal Business Name): JAMIE SMITH PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2022
Last Update Date: 07/04/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 BAY AVE
CLEARWATER FL
33756-5291
US

IV. Provider business mailing address

6262 142ND AVE N UNIT 406
CLEARWATER FL
33760-2769
US

V. Phone/Fax

Practice location:
  • Phone: 727-445-4700
  • Fax:
Mailing address:
  • Phone: 717-884-1423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number29395
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: