Provider Demographics
NPI:1992983001
Name:SMITH, TONYA LANETT (PA)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:LANETT
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1750
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-1153
Mailing Address - Country:US
Mailing Address - Phone:209-665-8566
Mailing Address - Fax:209-846-9641
Practice Address - Street 1:1552 COFFEE RD STE 200
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3122
Practice Address - Country:US
Practice Address - Phone:209-248-7168
Practice Address - Fax:209-846-9641
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA19549363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABO689ZMedicare PIN