Healthcare Provider Details

I. General information

NPI: 1720694326
Provider Name (Legal Business Name): MICHELLE SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 ANDREA CT
MELBOURNE FL
32934-7601
US

IV. Provider business mailing address

PO BOX 100108
GAINESVILLE FL
32610-0108
US

V. Phone/Fax

Practice location:
  • Phone: 321-848-4978
  • Fax:
Mailing address:
  • Phone: 352-273-5670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113742
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: