Basic Information
| Provider Information | |||||||||
| NPI: | 1982644134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | NADYA | ||||||||
| MiddleName: | ALEXANDRA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEONARD | ||||||||
| OtherFirstName: | NADYA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1190 RIDDLE ST | ||||||||
| Address2: | PO BOX 390 | ||||||||
| City: | DARRINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604361055 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1190 RIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | DARRINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604361055 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 12/05/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10004298 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8319246 | 05 | WA | MEDICAID |