Healthcare Provider Details

I. General information

NPI: 1093751265
Provider Name (Legal Business Name): MICHAEL L. SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 BILL OWENS PKWY
LONGVIEW TX
75604-6210
US

IV. Provider business mailing address

2010 BILL OWENS PKWY
LONGVIEW TX
75604-6210
US

V. Phone/Fax

Practice location:
  • Phone: 903-247-3400
  • Fax: 903-238-9183
Mailing address:
  • Phone: 903-247-3400
  • Fax: 903-238-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02652
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: