Provider Demographics
NPI:1114139474
Name:SMILEY, HERBERT WAYNE (PA)
Entity type:Individual
Prefix:MR
First Name:HERBERT
Middle Name:WAYNE
Last Name:SMILEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:HERBERT
Other - Middle Name:WAYNE
Other - Last Name:SMILEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:576 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1373
Mailing Address - Country:US
Mailing Address - Phone:757-314-7602
Mailing Address - Fax:
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1373
Practice Address - Country:US
Practice Address - Phone:757-314-7602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant