=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689996613
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICH WAVERLY SMITH PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2010
-----------------------------------------------------
Last Update Date | 02/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2154 SUTTON HOOTEN LN
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28551-8252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-566-3298
-----------------------------------------------------
Fax | 252-566-2829
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2154 SUTTON HOOTEN LN
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28551-8252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-566-3298
-----------------------------------------------------
Fax | 252-566-2829
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 102048
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------