Healthcare Provider Details

I. General information

NPI: 1487111969
Provider Name (Legal Business Name): DEREK LEE SMITH PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 SEMINARY ST
WARSAW MO
65355
US

IV. Provider business mailing address

33700 HILTY AVE
WARSAW MO
65355-5245
US

V. Phone/Fax

Practice location:
  • Phone: 660-438-6993
  • Fax:
Mailing address:
  • Phone: 417-855-9540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2018037417
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: