Provider Demographics
NPI:1720694326
Name:SMITH, MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
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:PO BOX 100108
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0108
Mailing Address - Country:US
Mailing Address - Phone:352-273-5670
Mailing Address - Fax:
Practice Address - Street 1:2330 ANDREA CT
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7601
Practice Address - Country:US
Practice Address - Phone:321-848-4978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9113742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant