MEDICARE: RONALD KENT SMITH III PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1184035305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD KENT SMITH III PA-C

Provider Business Mailing Address
First Line	:	1814 S CEDAR ST
Second Line	:
City	:	IMLAY CITY
State	:	MI
Zip	:	48444-9779
Country	:	US
Telephone Number	:	810-721-7476
Fax Number	:	810-721-7446

Provider Business Practice Location Address
First Line	:	5005 N. PIEDRAS
Second Line	:	WBAMC
City	:	FORT BLISS
State	:	TX
Zip	:	79920
Country	:	US
Telephone Number	:	915-742-4432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2014
Last Update Date	:	10/25/2021

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