Healthcare Provider Details

I. General information

NPI: 1679390470
Provider Name (Legal Business Name): BRIDGET SMART PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 N HANCOCK RD
CLERMONT FL
34711-5952
US

IV. Provider business mailing address

PO BOX 10222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-1150
  • Fax: 352-394-1560
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9118654
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: