Provider Demographics
NPI:1023630738
Name:SMITH, ALYSIA MOTA (PA-C)
Entity type:Individual
Prefix:
First Name:ALYSIA
Middle Name:MOTA
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 13
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:OK
Mailing Address - Zip Code:73834-0013
Mailing Address - Country:US
Mailing Address - Phone:719-459-1285
Mailing Address - Fax:
Practice Address - Street 1:610 N HOY ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:OK
Practice Address - Zip Code:73834-8933
Practice Address - Country:US
Practice Address - Phone:580-735-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA4487207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine