Provider Demographics
NPI:1235322181
Name:SMITH, MARK THOMAS (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:134 FIELD STONE DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37705-3336
Mailing Address - Country:US
Mailing Address - Phone:865-300-8084
Mailing Address - Fax:865-381-0533
Practice Address - Street 1:106 CREEK ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:TN
Practice Address - Zip Code:37769
Practice Address - Country:US
Practice Address - Phone:865-426-2186
Practice Address - Fax:865-426-9200
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN1001363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP81833Medicare UPIN