Provider Demographics
NPI:1114916475
Name:SMITH, LISA M (PAC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 196
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:GA
Mailing Address - Zip Code:31780-0196
Mailing Address - Country:US
Mailing Address - Phone:229-824-3438
Mailing Address - Fax:
Practice Address - Street 1:107 MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:GA
Practice Address - Zip Code:31780-5570
Practice Address - Country:US
Practice Address - Phone:229-824-7757
Practice Address - Fax:229-824-3497
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002904363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA002904OtherLICENSE