Provider Demographics
NPI:1548518780
Name:SMITH, CHRISTOPHER R (PA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-528-4975
Mailing Address - Fax:
Practice Address - Street 1:14547 BRUCE B DOWNS BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2709
Practice Address - Country:US
Practice Address - Phone:813-979-0440
Practice Address - Fax:813-355-5054
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHY569Y - TPAMedicare PIN
FLHY569Z - PASCOMedicare PIN