Provider Demographics
NPI:1306121512
Name:SMITH, GABRIEL REED (PA-C)
Entity type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:REED
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 1:1834 NE HANCOCK ST
Mailing Address - Street 2:APARTMENT 4
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4590
Mailing Address - Country:US
Mailing Address - Phone:503-209-4877
Mailing Address - Fax:
Practice Address - Street 1:1834 NE HANCOCK ST
Practice Address - Street 2:APARTMENT 4
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4590
Practice Address - Country:US
Practice Address - Phone:503-209-4877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9106181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant