Healthcare Provider Details

I. General information

NPI: 1558308122
Provider Name (Legal Business Name): JEFFREY M SMITH RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 WASHINGTON ST
WATERTOWN NY
13601-4031
US

IV. Provider business mailing address

PO BOX 91
WATERTOWN NY
13601-0091
US

V. Phone/Fax

Practice location:
  • Phone: 315-785-7009
  • Fax: 315-785-7566
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10439
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: