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General NPI Number Information
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NPI Number | 1558332650
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Entity Type | Individual
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Provider Name | LARRY DERRELL SMITH PA-C
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Gender | Male
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Dates
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Enumeration Date | 01/28/2006
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Last Update Date | 06/19/2025
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Provider Practice Location Address
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Address Line | 340 S WILLARD ST STE 101
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City | COTTONWOOD
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State | AZ
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Zip | 86326-4126
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Country | US
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Telephone | 928-649-7960
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Fax | 928-634-1117
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Provider Business Mailing Address
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Address Line | 1200 N BEAVER ST ATTN: PAYER CREDENTIALING
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City | FLAGSTAFF
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State | AZ
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Zip | 86001-3118
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Country | US
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Telephone | 928-213-6235
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA53072
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA53072
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1838
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License Number State | AZ
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