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General NPI Number Information
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NPI Number | 1750016879
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Entity Type | Individual
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Provider Name | TYSON SCOTT SMITH PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/21/2022
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Last Update Date | 01/23/2023
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Provider Practice Location Address
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Address Line | 325 CORDOVA ST APT 324
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City | PASADENA
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State | CA
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Zip | 91101-4692
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Country | US
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Telephone | 801-473-6501
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Fax |
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Provider Business Mailing Address
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Address Line | 8635 W 3RD ST STE 990W
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City | LOS ANGELES
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State | CA
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Zip | 90048-6116
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Country | US
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Telephone | 310-423-5900
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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 | 61389
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License Number State | CA
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