Provider Demographics
NPI:1902882509
Name:SMITH, WAYNE F (PAC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:F
Last Name:SMITH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 W BELVEDERE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5202
Mailing Address - Country:US
Mailing Address - Phone:410-601-2246
Mailing Address - Fax:
Practice Address - Street 1:2434 W BELVEDERE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5202
Practice Address - Country:US
Practice Address - Phone:410-601-2246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD970011676OtherRAILROAD MED
MD76IL7272Medicare PIN
MD970011676OtherRAILROAD MED
MDS56466Medicare UPIN