Provider Demographics
NPI:1548892110
Name:SMITH, CODY CHARLES (PA)
Entity type:Individual
Prefix:MR
First Name:CODY
Middle Name:CHARLES
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-7335
Mailing Address - Fax:
Practice Address - Street 1:3277 E LOUISE DR FL 2
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9359
Practice Address - Country:US
Practice Address - Phone:208-381-7335
Practice Address - Fax:208-381-7227
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57810363A00000X, 363AM0700X
IDPA-2484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical