Provider Demographics
NPI:1528051299
Name:MCKINNEY SMITH, LISA A (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:MCKINNEY SMITH
Suffix:
Gender:F
Credentials:DO
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 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2093
Mailing Address - Fax:423-390-3340
Practice Address - Street 1:105 W STONE DR STE 1J
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3365
Practice Address - Country:US
Practice Address - Phone:423-378-7654
Practice Address - Fax:423-578-8025
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO1464207RP1001X
VA0102201581207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005651B56OtherTRAILBLAZERS MEDICARE
TN3300707Medicaid
VAP00149425OtherPALMETTO RR MEDICARE
TNP00149425OtherPALMETTO RR MEDICARE
TN3300708Medicare PIN
TNI11670Medicare UPIN
TN3300707Medicare ID - Type Unspecified
VA018402W82Medicare PIN
TNP00370003Medicare PIN
VA005651B56OtherTRAILBLAZERS MEDICARE
TN3300707Medicaid