Provider Demographics
NPI:1972735751
Name:SMITH, SAMANTHA BROOKS WOOD (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:BROOKS WOOD
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:BROOKS
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:889 ALDER AVE
Mailing Address - Street 2:#203
Mailing Address - City:INCLINE VILLAGE
Mailing Address - State:NV
Mailing Address - Zip Code:89451-8203
Mailing Address - Country:US
Mailing Address - Phone:775-832-5200
Mailing Address - Fax:775-832-5205
Practice Address - Street 1:889 ALDER AVE
Practice Address - Street 2:#203
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451-8203
Practice Address - Country:US
Practice Address - Phone:775-832-5200
Practice Address - Fax:775-832-5205
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20982363A00000X
NVPA1180363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant