Healthcare Provider Details

I. General information

NPI: 1124074943
Provider Name (Legal Business Name): MICHAEL BENJAMIN SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 S DENVER ST
FAIRCHILD AFB WA
99011-8650
US

IV. Provider business mailing address

10012 S STANGLAND RD
MEDICAL LAKE WA
99022-9409
US

V. Phone/Fax

Practice location:
  • Phone: 590-247-5414
  • Fax:
Mailing address:
  • Phone: 509-299-6678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004669
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: