Provider Demographics
NPI:1699241935
Name:SMITH, KRISTEN (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
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 1:331 OAK MANOR DR STE 201
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5555
Mailing Address - Country:US
Mailing Address - Phone:443-333-1894
Mailing Address - Fax:
Practice Address - Street 1:331 OAK MANOR DR STE 201
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5555
Practice Address - Country:US
Practice Address - Phone:443-333-1894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-14
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MDC0007292363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical