Provider Demographics
NPI:1992794929
Name:SMITH, PRESTON S (PA-C)
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:S
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 E HAWAII AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6011
Practice Address - Country:US
Practice Address - Phone:208-468-5930
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010145450OtherBLUE SHIELD
IDDAGV3OtherBLUE CROSS
ID000010145449OtherBLUE SHIELD
ID806749400Medicaid
IDPAG001OtherBLUE CROSS
IDP00160006OtherRAILROAD MEDICARE
Q04823Medicare UPIN
ID000010145450OtherBLUE SHIELD