1649437997 NPI number — MS. RHONDA MICHELLE SMITH PHYSICIAN ASSISTANT

Table of content: MS. RHONDA MICHELLE SMITH PHYSICIAN ASSISTANT (NPI 1649437997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649437997 NPI number — MS. RHONDA MICHELLE SMITH PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
RHONDA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
RHONDA
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICIAN ASSISTANT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649437997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 MABLE AVENUE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-571-1992
Provider Business Mailing Address Fax Number:
209-571-1994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 MABLE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-571-1992
Provider Business Practice Location Address Fax Number:
209-571-1994
Provider Enumeration Date:
05/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA14435 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA14435 . This is a "PA LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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