Healthcare Provider Details

I. General information

NPI: 1235205865
Provider Name (Legal Business Name): LAWRENCE C. SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 HARRISON AVE
EUREKA CA
95503
US

IV. Provider business mailing address

3116 HARRISON AVE
EUREKA CA
95503
US

V. Phone/Fax

Practice location:
  • Phone: 707-444-3885
  • Fax: 707-444-7843
Mailing address:
  • Phone: 707-444-3885
  • Fax: 707-444-7843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10280
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: