Provider Demographics
NPI:1053697565
Name:SMITH, JOANNA P (PA-C)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:P
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2505 MISSION DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-9508
Mailing Address - Country:US
Mailing Address - Phone:573-681-3759
Mailing Address - Fax:573-681-3659
Practice Address - Street 1:2505 MISSION DR
Practice Address - Street 2:SUITE 200
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-9508
Practice Address - Country:US
Practice Address - Phone:573-681-3759
Practice Address - Fax:573-681-3659
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2020-12-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2011033714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO140940008Medicare PIN