Healthcare Provider Details

I. General information

NPI: 1376689372
Provider Name (Legal Business Name): KENNETH ERIC SMOOT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SW ARCHER RD
GAINESVILLE FL
32608-1135
US

IV. Provider business mailing address

1601 SW ARCHER RD.
GAINESVILLE FL
32608
US

V. Phone/Fax

Practice location:
  • Phone: 352-376-1611
  • Fax: 352-379-4015
Mailing address:
  • Phone: 352-376-1611
  • Fax: 352-379-4015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003686
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: