MEDICARE: TINA SUE-MARIE ROBERTS-SMITH MPAS,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	363AM0700X	Medical Physician Assistant	PA3744	FL

General Provider Information

NPI Number	:	1235186578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA SUE-MARIE ROBERTS-SMITH MPAS,PA-C

Provider Business Mailing Address
First Line	:	600 W PLYMOUTH AVE
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-3260
Country	:	US
Telephone Number	:	386-738-0322
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 W PLYMOUTH AVE
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-3260
Country	:	US
Telephone Number	:	386-738-0322
Fax Number	:	386-738-0628

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

Provider Enumeration Date	:	05/30/2006
Last Update Date	:	07/08/2007

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