Provider Demographics
NPI:1528153863
Name:BYAM-SMITH, MARY PATRICIA (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:BYAM-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 1:1620 S 198TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130
Mailing Address - Country:US
Mailing Address - Phone:801-529-3627
Mailing Address - Fax:402-939-0465
Practice Address - Street 1:1620 S 198TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130
Practice Address - Country:US
Practice Address - Phone:801-529-3627
Practice Address - Fax:402-939-0465
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5102257-1206363AM0700X
NE1670363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1033468OtherNCCPA CERTIFICATE NUMBER
S81191Medicare UPIN