Provider Demographics
NPI:1972675387
Name:SMITH, MARK A (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:5323 HARRY HINES BLVD STOP 7200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-8095
Mailing Address - Country:US
Mailing Address - Phone:214-648-3111
Mailing Address - Fax:402-559-9840
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-8095
Practice Address - Country:US
Practice Address - Phone:214-648-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPA2869363A00000X
NE686363AM0700X
TX16959363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ949901Medicaid
S93908Medicare UPIN
AZ949901Medicaid