Provider Demographics
NPI:1962519082
Name:SMITH, GREGORY (PA-C)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:SMITH
Suffix:
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 1:1452 STATE ROUTE 351
Mailing Address - Street 2:
Mailing Address - City:ENON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:16120-2622
Mailing Address - Country:US
Mailing Address - Phone:724-336-5822
Mailing Address - Fax:
Practice Address - Street 1:207 A SECOND STREET
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:PA
Practice Address - Zip Code:16115
Practice Address - Country:US
Practice Address - Phone:724-827-8137
Practice Address - Fax:724-827-2578
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA0004666L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S61934Medicare UPIN
PA015325LCKMedicare PIN