Provider Demographics
NPI:1700295755
Name:SMITH, PAUL (ATC)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 UNIVERSITY DR
Mailing Address - Street 2:MS 1021
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83725-0001
Mailing Address - Country:US
Mailing Address - Phone:208-426-3944
Mailing Address - Fax:208-426-1778
Practice Address - Street 1:70 TOWER PARKWAY
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:860-834-2731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-4312255A2300X
CT12272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer