Provider Demographics
NPI:1316930886
Name:SMITH, STACY P (C-PA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:P
Last Name:SMITH
Suffix:
Gender:F
Credentials:C-PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 37TH PL STE 201
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4818
Mailing Address - Country:US
Mailing Address - Phone:772-492-7051
Mailing Address - Fax:772-492-7048
Practice Address - Street 1:1040 37TH PL STE 201
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-492-7051
Practice Address - Fax:772-492-7048
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101489363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP34597Medicare UPIN
FLE5768YMedicare PIN