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General NPI Number Information
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NPI Number | 1477013456
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Entity Type | Individual
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Provider Name | ERICA KELLYN SMITH PA-C, ATC
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Gender | Female
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Dates
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Enumeration Date | 03/25/2019
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Last Update Date | 02/20/2024
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Provider Practice Location Address
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Address Line | 2100 HIGHWAY 61 N
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City | VICKSBURG
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State | MS
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Zip | 39183-8211
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Country | US
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Telephone | 601-883-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 4 GLENWOOD CIR
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City | VICKSBURG
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State | MS
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Zip | 39180-3942
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Country | US
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Telephone | 601-540-4936
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | PA00777
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA00777
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License Number State | MS
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