=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346693314
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA SMITH PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2016
-----------------------------------------------------
Last Update Date | 12/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 JACKSON ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52211-7711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-522-7221
-----------------------------------------------------
Fax | 641-522-5816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 JACKSON ST PO BOX 527
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52211-7711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-522-7221
-----------------------------------------------------
Fax | 641-522-5816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 083680
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------