Provider Demographics
NPI:1194783571
Name:SMITH, WILLIAM FLEETWOOD (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:FLEETWOOD
Last Name:SMITH
Suffix:
Gender:M
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 1:6002 SCALYBARK RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-1265
Mailing Address - Country:US
Mailing Address - Phone:919-471-6051
Mailing Address - Fax:
Practice Address - Street 1:11-C DURHAM VA MEDICAL CENTER
Practice Address - Street 2:502 FULTON ST
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705
Practice Address - Country:US
Practice Address - Phone:919-286-0411
Practice Address - Fax:919-383-6128
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCVA D000Medicare UPIN