Provider Demographics
NPI:1588691901
Name:SMITH, RICHARD ANTHONY SR (PA-C)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ANTHONY
Last Name:SMITH
Suffix:SR
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 1:41106 STATE ROAD 64 E
Mailing Address - Street 2:
Mailing Address - City:MYAKKA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34251-9355
Mailing Address - Country:US
Mailing Address - Phone:941-322-8310
Mailing Address - Fax:
Practice Address - Street 1:41106 STATE ROAD 64 E
Practice Address - Street 2:
Practice Address - City:MYAKKA CITY
Practice Address - State:FL
Practice Address - Zip Code:34251-9355
Practice Address - Country:US
Practice Address - Phone:941-322-8310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2907305 01Medicaid
FLE3619UMedicare PIN
FLE3619TMedicare PIN
FLS99219Medicare UPIN