Healthcare Provider Details

I. General information

NPI: 1689849275
Provider Name (Legal Business Name): SMITH PHYSICIAN ASSISTANTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 WASHINGTON ST
WATERTOWN NY
13601-4031
US

IV. Provider business mailing address

445 FACTORY ST PO BOX 91
WATERTOWN NY
13601-2729
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 Number0057341
License Number StateNY

VIII. Authorized Official

Name: MILAGROS SMITH
Title or Position: RPA-C
Credential: RPA-C
Phone: 315-785-7009