Healthcare Provider Details

I. General information

NPI: 1205502200
Provider Name (Legal Business Name): ZACHARY JOSEPH SMITH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 STATE ROUTE 37
AKWESASNE NY
13655-3109
US

IV. Provider business mailing address

412 STATE ROUTE 37
AKWESASNE NY
13655-3109
US

V. Phone/Fax

Practice location:
  • Phone: 518-358-3141
  • Fax:
Mailing address:
  • Phone: 518-358-3141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number027043
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: