NPIMap

Individual provider Active NPI

Larry Derrell Smith, PA-C

  • Physician Assistant
  • Cottonwood, AZ
National Provider Identifier
1558332650
Registry record updated Jun 19, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
1838 Issued in AZ
Practice address
340 S Willard St Ste 101
Cottonwood, AZ 86326-4126
Phone
(928) 649-7960
Fax
(928) 634-1117
NPI assigned
Jan 28, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 19, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X PA53072 CA
Surgical Physician Assistant 363AS0400X PA53072 CA
Physician Assistant 363A00000X 1838 AZ Primary

Addresses

Primary practice location

340 S Willard St Ste 101
Cottonwood, AZ 86326-4126

Mailing address

1200 N Beaver St
Attn: Payer Credentialing
Flagstaff, AZ 86001-3118
Phone (928) 213-6235

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ, CA2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20071226000077 AZ Practitioner - Physician Assistant 2264522572 Reassigns benefits to 2 organizations
I20160119001047 CA Practitioner - Physician Assistant 2264522572 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 1994
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

1215 N Beaver St
Suite 203
Flagstaff, AZ 86001-3126
Phone (928) 773-2249

2000 S Thompson St
Flagstaff, AZ 86001-8759
Phone (928) 226-6400

269 S Candy LN
Cottonwood, AZ 86326-4158
Phone (928) 639-6000

340 S Willard St
Cottonwood, AZ 86326-4126
Phone (928) 639-6025

7810 N US Hwy 89
Flagstaff, AZ 86004-6255
Phone (928) 522-8375

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
53072CAMDOrthodontics and Dentofacial Orthopedic Dentist
1838AZMDPhysical Therapist
PA53072CAMDSurgical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Flagstaff Pathology Associates Current Accepting new patients
Northern Arizona Healthcare Corporation CurrentSince May 15, 2025 Accepting new patients
Northern Arizona Healthcare Corporation CurrentSince May 15, 2025 Accepting new patients
Apogee Outpatient Surgery Center Past Accepting new patients
Deseret Family Practice, LTD. Past Accepting new patients

Locations

340 S Willard St
Ste 101
Cottonwood, AZ 86326
Phone (928) 639-2015

269 S Candy Ln
Cottonwood, AZ 86326
Phone (928) 634-2251

1215 N Beaver St
Ste 203
Flagstaff, AZ 86001
Phone (928) 773-2249

1200 N Beaver St
Flagstaff, AZ 86001
Phone (928) 213-6235

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1138406400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1750291200000",
    "number": "1558332650",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 N BEAVER ST",
            "address_2": "ATTN: PAYER CREDENTIALING",
            "city": "FLAGSTAFF",
            "state": "AZ",
            "postal_code": "860013118",
            "telephone_number": "928-213-6235"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "340 S WILLARD ST STE 101",
            "city": "COTTONWOOD",
            "state": "AZ",
            "postal_code": "863264126",
            "telephone_number": "928-649-7960",
            "fax_number": "928-634-1117"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SMITH",
        "first_name": "LARRY",
        "middle_name": "DERRELL",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-01-28",
        "last_updated": "2025-06-19",
        "certification_date": "2025-06-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "PA53072",
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "CA",
            "license": "PA53072",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "AZ",
            "license": "1838",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Cottonwood, AZ

Sources for this page

Verify at the official NPI Registry.