Provider Demographics
NPI:1205023769
Name:SMITH, PHILIP ALLEN (PA-C)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:ALLEN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 AIR NATIONAL GUARD RD BLDG 43
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-9752
Mailing Address - Country:US
Mailing Address - Phone:518-344-3402
Mailing Address - Fax:515-344-3428
Practice Address - Street 1:1 AIR NATIONAL GUARD RD
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302
Practice Address - Country:US
Practice Address - Phone:518-344-3402
Practice Address - Fax:518-344-3428
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007448363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical