Individual
MR. CODY CHARLES SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
3277 E LOUISE DR FL 2, MERIDIAN, ID 83642-9359
(208) 381-7335
(208) 381-7227
Mailing address
190 E BANNOCK ST, BOISE, ID 83712-6241
(208) 381-7335
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-2484
ID
363A00000X
Physician Assistant
PA57810
CA
363AM0700X
Medical Physician Assistant
PA57810
CA
Other
Enumeration date
02/11/2020
Last updated
08/08/2024
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