Provider Demographics
NPI:1427521533
Name:SMITH, STEPHANIE MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:F
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 1:2025 WILLIAMS FARM RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23457-1390
Mailing Address - Country:US
Mailing Address - Phone:757-705-9572
Mailing Address - Fax:
Practice Address - Street 1:2025 WILLIAMS FARM RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23457-1390
Practice Address - Country:US
Practice Address - Phone:757-705-9572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-007080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant