Provider Demographics
NPI:1538255476
Name:SMITH, CHRISTOPHER SHANE (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:SHANE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:C
Other - Middle Name:SHANE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:4828 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2341
Mailing Address - Country:US
Mailing Address - Phone:850-477-8109
Mailing Address - Fax:850-478-2412
Practice Address - Street 1:5147 N 9TH AVE STE 311
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8770
Practice Address - Country:US
Practice Address - Phone:850-477-2597
Practice Address - Fax:850-478-7941
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291473500Medicaid
970030058OtherRAILROAD MEDICARE
AL059076677OtherBCBS OF ALABAMA
AL009913575Medicaid