Basic Information
| Provider Information | |||||||||
| NPI: | 1134105059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | FRANK | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10801 OKLAHOMA ROAD | ||||||||
| Address2: | |||||||||
| City: | HACKETT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793129274 | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 KERR AVE | ||||||||
| Address2: | |||||||||
| City: | POTEAU | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749535270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186491100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 09/26/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA03545 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA982 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 165646401 | 05 | TX | MEDICAID |