Healthcare Provider Details

I. General information

NPI: 1114128956
Provider Name (Legal Business Name): CAROLYN ANN SMITH P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 BISHOP ST 220
SAN LUIS OBISPO CA
93401-4635
US

IV. Provider business mailing address

101 E REDLANDS BLVD 212
REDLANDS CA
92373-4775
US

V. Phone/Fax

Practice location:
  • Phone: 805-541-0668
  • Fax: 805-541-8213
Mailing address:
  • Phone: 909-335-8649
  • Fax: 909-335-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA14769
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: