Provider Demographics
NPI:1619976149
Name:SMITH, GRETCHEN LEE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
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 1:1650 UNION AVE
Mailing Address - Street 2:PBG EMPLOYEE HEALTH & WELLNESS CENTER
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-1917
Mailing Address - Country:US
Mailing Address - Phone:410-554-7874
Mailing Address - Fax:
Practice Address - Street 1:1650 UNION AVE
Practice Address - Street 2:PBG EMPLOYEE HEALTH & WELLNESS CENTER
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-1917
Practice Address - Country:US
Practice Address - Phone:410-554-7874
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant