Healthcare Provider Details

I. General information

NPI: 1407349319
Provider Name (Legal Business Name): ANNA JANE SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE STE 6600
ALBUQUERQUE NM
87106-5411
US

IV. Provider business mailing address

3292 NIGHTHAWK AVE
BRAYTON IA
50042-7545
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: