Provider Demographics
NPI:1104978576
Name:SMITH, LAURA K (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:K
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-1826
Mailing Address - Country:US
Mailing Address - Phone:304-927-8138
Mailing Address - Fax:304-927-8198
Practice Address - Street 1:146 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1826
Practice Address - Country:US
Practice Address - Phone:304-927-8138
Practice Address - Fax:304-927-8198
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006054Medicaid
COPA80961Medicare PIN