Provider Demographics
NPI:1366523656
Name:SMITH, NATASHA L (PA-C, MHSA)
Entity type:Individual
Prefix:MRS
First Name:NATASHA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C, MHSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5974
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:SUITE 411
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-438-7373
Practice Address - Fax:313-438-7375
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004768363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004768OtherLICENSE
1071652OtherNCCPA CERTIFICATE