MEDICARE: RICHARD LEE SMITH 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
2	363AS0400X	Surgical Physician Assistant	PA03242	TX
3	363A00000X	Physician Assistant	PA03242	TX

General Provider Information

NPI Number	:	1912088147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD LEE SMITH PA-C

Provider Business Mailing Address
First Line	:	4444 HERITAG TRCE PKWY STE 408
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8944
Country	:	US
Telephone Number	:	817-283-5252
Fax Number	:	817-283-5283

Provider Business Practice Location Address
First Line	:	4444 HERITAGE TRACE PKWY STE 408
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8944
Country	:	US
Telephone Number	:	817-283-5252
Fax Number	:	817-283-5283

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

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	11/03/2022

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