Healthcare Provider Details

I. General information

NPI: 1588691901
Provider Name (Legal Business Name): RICHARD ANTHONY SMITH SR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41106 STATE ROAD 64 E
MYAKKA CITY FL
34251-9355
US

IV. Provider business mailing address

41106 STATE ROAD 64 E
MYAKKA CITY FL
34251-9355
US

V. Phone/Fax

Practice location:
  • Phone: 941-322-8310
  • Fax:
Mailing address:
  • Phone: 941-322-8310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101104
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: