Healthcare Provider Details

I. General information

NPI: 1316839590
Provider Name (Legal Business Name): GABRIEL JOHN SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 US HIGHWAY 2
CRYSTAL FALLS MI
49920-1045
US

IV. Provider business mailing address

7513 COUNTY 527 L RD
GLADSTONE MI
49837-9109
US

V. Phone/Fax

Practice location:
  • Phone: 906-875-4486
  • Fax:
Mailing address:
  • Phone: 906-399-2784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601013267
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: