Provider Demographics
NPI:1144878059
Name:SMITH, SAMUEL DENNISON (PAC, ATC)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DENNISON
Last Name:SMITH
Suffix:
Gender:M
Credentials:PAC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-8441
Mailing Address - Country:US
Mailing Address - Phone:802-349-2194
Mailing Address - Fax:
Practice Address - Street 1:2200 BRYANT WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1120
Practice Address - Country:US
Practice Address - Phone:541-884-7746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1205273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty