Provider Demographics
NPI:1013905793
Name:SMITH, JEFFREY D (PA C)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8985
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-2985
Mailing Address - Country:US
Mailing Address - Phone:208-989-0598
Mailing Address - Fax:
Practice Address - Street 1:7979 W RIFLEMAN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9066
Practice Address - Country:US
Practice Address - Phone:208-989-0598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA383207X00000X
IDPA-383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806233100Medicaid
ID1667400Medicare ID - Type Unspecified
ID806233100Medicaid