Provider Demographics
NPI:1124074943
Name:SMITH, MICHAEL BENJAMIN (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BENJAMIN
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 1:10012 S STANGLAND RD
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-9409
Mailing Address - Country:US
Mailing Address - Phone:509-299-6678
Mailing Address - Fax:
Practice Address - Street 1:2505 S DENVER ST
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011-8650
Practice Address - Country:US
Practice Address - Phone:590-247-5414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA10004669OtherWA STATE MED LICENSE
1030141OtherNCCPA NUMBER