1366523656 NPI number — MRS. NATASHA L SMITH PA-C, MHSA

Table of content: MRS. NATASHA L SMITH PA-C, MHSA (NPI 1366523656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366523656 NPI number — MRS. NATASHA L SMITH PA-C, MHSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
NATASHA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C, MHSA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366523656
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1420 STEPHENSON HWY
Provider Second Line Business Mailing Address:
SUITE 400-CREDENTIALING
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48083-1189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-581-5974
Provider Business Mailing Address Fax Number:
248-581-5640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18181 OAKWOOD BLVD
Provider Second Line Business Practice Location Address:
SUITE 411
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48124-5032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-438-7373
Provider Business Practice Location Address Fax Number:
313-438-7375
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  5601004768 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5601004768 . This is a "LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1071652 . This is a "NCCPA CERTIFICATE" identifier . This identifiers is of the category "OTHER".




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