Healthcare Provider Details

I. General information

NPI: 1134580079
Provider Name (Legal Business Name): JOSEPH SMITH II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 E 84TH ST
CHICAGO IL
60619-5802
US

IV. Provider business mailing address

654 E 84TH ST
CHICAGO IL
60619-5802
US

V. Phone/Fax

Practice location:
  • Phone: 312-927-1276
  • Fax:
Mailing address:
  • Phone: 312-927-1276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6345
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number123456
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: