Provider Demographics
NPI:1366428203
Name:SMITH, LAURA C (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 W HARVARD STE 310
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-5653
Mailing Address - Country:US
Mailing Address - Phone:541-672-7546
Mailing Address - Fax:541-675-8446
Practice Address - Street 1:1813 W HARVARD AVE STE 310
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2756
Practice Address - Country:US
Practice Address - Phone:541-672-7546
Practice Address - Fax:541-675-8446
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00905363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0245490OtherDEPT OF LABOR AND INDUSTRIES
OR151228Medicaid
ORP80101Medicare UPIN
OR151228Medicaid
ORR145579Medicare PIN