MEDICARE: DAPHENE SMITH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	085002952	IL
2	363A00000X	Physician Assistant	009234	GA
3	207P00000X	Emergency Medicine Physician	085-002952	IL
4	207P00000X	Emergency Medicine Physician	2008018559	MO
5	363A00000X	Physician Assistant	085002952	IL

General Provider Information

NPI Number	:	1497869689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAPHENE SMITH PA

Provider Business Mailing Address
First Line	:	1825 HIGHWAY 34 E STE 1200
Second Line	:
City	:	NEWNAN
State	:	GA
Zip	:	30265-6416
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 REGENCY PARK DR STE 110
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-7076
Country	:	US
Telephone Number	:	404-996-0126
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	08/09/2023

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Directions to “ DAPHENE SMITH PA” Practice Location

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