Healthcare Provider Details

I. General information

NPI: 1598431231
Provider Name (Legal Business Name): OLIVER SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

IV. Provider business mailing address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

V. Phone/Fax

Practice location:
  • Phone: 845-333-7575
  • Fax: 845-333-1454
Mailing address:
  • Phone: 845-333-7575
  • Fax: 845-333-1454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number027026-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: