Provider Demographics
NPI:1215970025
Name:SMITH, MICHAEL A (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 BELANGER ST
Mailing Address - Street 2:STE 101
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4463
Mailing Address - Country:US
Mailing Address - Phone:610-428-7151
Mailing Address - Fax:985-850-6221
Practice Address - Street 1:1250 S CEDAR CREST BLVD
Practice Address - Street 2:STE 310
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6224
Practice Address - Country:US
Practice Address - Phone:610-402-6890
Practice Address - Fax:610-402-6892
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051316363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA071770Medicare ID - Type UnspecifiedMEDICARE
PAP94339Medicare UPIN