Provider Demographics
NPI:1902340862
Name:SMITH, MARISA DANIELLE (PA)
Entity Type:Individual
Prefix:MS
First Name:MARISA
Middle Name:DANIELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7408 SIEMENS RD STE A
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-8317
Mailing Address - Country:US
Mailing Address - Phone:919-404-8599
Mailing Address - Fax:919-404-8673
Practice Address - Street 1:6026 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3899
Practice Address - Country:US
Practice Address - Phone:919-848-0132
Practice Address - Fax:919-848-0277
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06883363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant