1669787032 NPI number — MR. KENNETH MONDRE SMITH PHYSICIAN ASSISTANT

Table of content: MR. KENNETH MONDRE SMITH PHYSICIAN ASSISTANT (NPI 1669787032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669787032 NPI number — MR. KENNETH MONDRE SMITH PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KENNETH
Provider Middle Name:
MONDRE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669787032
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24124 CINCO VILLAGE CENTER BLVD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
KATY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77494-8396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-693-5698
Provider Business Mailing Address Fax Number:
281-693-5690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24124 CINCO VILLAGE CENTER BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
KATY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77494-8396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-693-5698
Provider Business Practice Location Address Fax Number:
281-693-5690
Provider Enumeration Date:
08/10/2010

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:  PA06722 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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