Healthcare Provider Details

I. General information

NPI: 1972836609
Provider Name (Legal Business Name): KRISTA M SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 07/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 RIDGEWAY AVE SUITE 440
ROCHESTER NY
14626-4296
US

IV. Provider business mailing address

2655 RIDGEWAY AVE SUITE 440
ROCHESTER NY
14626-4296
US

V. Phone/Fax

Practice location:
  • Phone: 585-723-7705
  • Fax: 585-368-3219
Mailing address:
  • Phone: 585-723-7705
  • Fax: 585-368-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number020496
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: