Healthcare Provider Details

I. General information

NPI: 1053444679
Provider Name (Legal Business Name): NICHOLE M SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 WYOMING SPGS SUITE 600
ROUND ROCK TX
78681-4303
US

IV. Provider business mailing address

7200 WYOMING SPGS SUITE 600
ROUND ROCK TX
78681-4303
US

V. Phone/Fax

Practice location:
  • Phone: 512-244-1995
  • Fax: 512-244-2090
Mailing address:
  • Phone: 512-244-1995
  • Fax: 512-244-2090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02319
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: