Basic Information
| Provider Information | |||||||||
| NPI: | 1588650501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YORK | ||||||||
| OtherFirstName: | MARA | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036108092 | ||||||||
| FaxNumber: | 6036108096 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 CORPORATE DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036108092 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0392P | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 3083043 | 05 | NH | MEDICAID |