MEDICARE: MS. MARISA DANIELLE SMITH PA

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	0010-06883	NC

General Provider Information

NPI Number	:	1902340862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARISA DANIELLE SMITH PA

Provider Business Mailing Address
First Line	:	7408 SIEMENS RD STE A
Second Line	:
City	:	WENDELL
State	:	NC
Zip	:	27591-8317
Country	:	US
Telephone Number	:	919-404-8599
Fax Number	:	919-404-8673

Provider Business Practice Location Address
First Line	:	6026 SIX FORKS RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-3899
Country	:	US
Telephone Number	:	919-848-0132
Fax Number	:	919-848-0277

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

Provider Enumeration Date	:	12/12/2016
Last Update Date	:	11/15/2023

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