Provider Demographics
NPI:1366968398
Name:SMITH, BENNETT BRENT (PA-C)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:BRENT
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 1:825 ADAMS ST. SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801
Mailing Address - Country:US
Mailing Address - Phone:256-536-9020
Mailing Address - Fax:256-536-9053
Practice Address - Street 1:825 ADAMS ST. SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-536-9020
Practice Address - Fax:256-536-9053
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1856363A00000X
AL1277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant