Healthcare Provider Details

I. General information

NPI: 1649555251
Provider Name (Legal Business Name): COREY H SMOCK P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 LAMB CIR SUITE L-760
CHRISTIANSBURG VA
24073-6344
US

IV. Provider business mailing address

2900 LAMB CIR SUITE L-760
CHRISTIANSBURG VA
24073-6344
US

V. Phone/Fax

Practice location:
  • Phone: 540-731-2436
  • Fax: 540-731-2439
Mailing address:
  • Phone: 540-731-2436
  • Fax: 540-731-2439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110004224
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: