Provider Demographics
NPI:1285788679
Name:SMITH, GREGORY E (PA)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:E
Last Name:SMITH
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Gender:M
Credentials:PA
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Mailing Address - Street 1:1905 SKIBO RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-0260
Mailing Address - Country:US
Mailing Address - Phone:910-864-4357
Mailing Address - Fax:910-221-0099
Practice Address - Street 1:1905 SKIBO ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-0261
Practice Address - Country:US
Practice Address - Phone:910-864-4357
Practice Address - Fax:910-221-0099
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
NC103971208000000X, 363AM0700X
NC145009363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC103971OtherLICENSE NUMBER
NC103971OtherLICENSE NUMBER
NCMD1270216OtherDEA NUMBER