Healthcare Provider Details

I. General information

NPI: 1629321021
Provider Name (Legal Business Name): MARK SAMUEL SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16000 JOHNSTON MEMORIAL DR FOURTH FLOOR
ABINGDON VA
24211-7659
US

IV. Provider business mailing address

16000 JOHNSTON MEMORIAL DR FOURTH FLOOR
ABINGDON VA
24211-7659
US

V. Phone/Fax

Practice location:
  • Phone: 276-258-4050
  • Fax: 276-258-4056
Mailing address:
  • Phone: 276-258-4050
  • Fax: 276-258-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2210
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110004485
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: