Provider Demographics
NPI:1053383331
Name:SMITH, PEGGIE A (PA-C)
Entity type:Individual
Prefix:MS
First Name:PEGGIE
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PEGGIEA
Other - Middle Name:A
Other - Last Name:GRASLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:850 HARVARD WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2055
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:75 PRINGLE WAY STE 401
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1476
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-2973
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1053383331Medicaid
12509167OtherCAQH
NV1053383331Medicaid
NVGX324ZMedicare PIN