Basic Information
| Provider Information | |||||||||
| NPI: | 1972675387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 988095 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025598662 | ||||||||
| FaxNumber: | 4025599840 | ||||||||
| Practice Location | |||||||||
| Address1: | 988095 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025598662 | ||||||||
| FaxNumber: | 4025599840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 10/27/2007 | ||||||||
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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 | 363A00000X | PA2869 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 686 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 949901 | 05 | AZ | MEDICAID |