Provider Demographics
NPI:1144672023
Name:SMOLA, JACQUELINE (PA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SMOLA
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 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:850 ENTERPRISE PKWY
Practice Address - Street 2:SUITE 2000
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6251
Practice Address - Country:US
Practice Address - Phone:757-534-9988
Practice Address - Fax:757-534-5688
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110005399363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant