Healthcare Provider Details

I. General information

NPI: 1053064154
Provider Name (Legal Business Name): CAROLINE WADE SMITH PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 JOHNSON FY RD NE
SANDY SPRINGS GA
30342-1605
US

IV. Provider business mailing address

1001 JOHNSON FY RD NE
SANDY SPRINGS GA
30342-1605
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax:
Mailing address:
  • Phone: 404-785-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14035
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: