Basic Information
| Provider Information | |||||||||
| NPI: | 1922019488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMOLARZ | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | HARGRAVE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARGRAVE | ||||||||
| OtherFirstName: | KELLI | ||||||||
| OtherMiddleName: | BROOKE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9149 ESTATE THOMAS | ||||||||
| Address2: | STE 308 | ||||||||
| City: | ST THOMAS | ||||||||
| State: | VI | ||||||||
| PostalCode: | 008023132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3407748881 | ||||||||
| FaxNumber: | 3407741569 | ||||||||
| Practice Location | |||||||||
| Address1: | 9149 ESTATE THOMAS | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | ST THOMAS | ||||||||
| State: | VI | ||||||||
| PostalCode: | 008022615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3407792663 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA04179 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 027 | VI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.