Basic Information
| Provider Information | |||||||||
| NPI: | 1578552857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TRUDY | ||||||||
| MiddleName: | LENNETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARTER | ||||||||
| OtherFirstName: | TRUDY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2435 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764308020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3258934010 | ||||||||
| FaxNumber: | 3258934042 | ||||||||
| Practice Location | |||||||||
| Address1: | 1712 NORTH ACCESS ROAD | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3258934010 | ||||||||
| FaxNumber: | 3258934042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 03/05/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA01805 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.