Provider Demographics
NPI:1366593956
Name:SMITH, SAMONE D (PA-C)
Entity type:Individual
Prefix:
First Name:SAMONE
Middle Name:D
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-727-2111
Mailing Address - Fax:
Practice Address - Street 1:2405 S CLEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-5775
Practice Address - Country:US
Practice Address - Phone:254-618-1888
Practice Address - Fax:254-519-5264
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05059363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q78771Medicare UPIN
TX8J4280Medicare PIN
TX8J8387Medicare PIN