Healthcare Provider Details

I. General information

NPI: 1114916475
Provider Name (Legal Business Name): LISA M SMITH PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 MAIN ST
PLAINS GA
31780-5570
US

IV. Provider business mailing address

PO BOX 196
PLAINS GA
31780-0196
US

V. Phone/Fax

Practice location:
  • Phone: 229-824-7757
  • Fax: 229-824-3497
Mailing address:
  • Phone: 229-824-3438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002904
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: