=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821740788
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA KORYN SMITH PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2022
-----------------------------------------------------
Last Update Date | 01/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 503 N 21ST ST
-----------------------------------------------------
City | CAMP HILL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17011-2204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 290-171-7763
-----------------------------------------------------
Fax | 717-763-2803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3695 ROUNDTOP RD
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17022-9057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-756-7220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------