Basic Information
Provider Information
NPI: 1033558465
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITHERS
FirstName: KRYSTAL
MiddleName:  
NamePrefix: MRS.
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 208 MACCORKLE AVE SE
Address2:  
City: CHARLESTON
State: WV
PostalCode: 253141160
CountryCode: US
TelephoneNumber: 3043434300
FaxNumber: 3043435473
Practice Location
Address1: 208 MACCORKLE AVE SE
Address2:  
City: CHARLESTON
State: WV
PostalCode: 253141160
CountryCode: US
TelephoneNumber: 3043434300
FaxNumber: 3043435473
Other Information
ProviderEnumerationDate: 06/19/2013
LastUpdateDate: 07/05/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363AM0700X01725WVY Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical

ID Information
IDTypeStateIssuerDescription
103355846501 NPIOTHER


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