Provider Demographics
NPI:1972786903
Name:SMITH, CAROLINE O (PA-C)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:O
Last Name:SMITH
Suffix:
Gender:F
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 1:96 E TEAGUE BAY DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3093
Mailing Address - Country:US
Mailing Address - Phone:203-572-2439
Mailing Address - Fax:
Practice Address - Street 1:1670 ST VINCENTS WAY
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8447
Practice Address - Country:US
Practice Address - Phone:904-602-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002022363A00000X
FLPA9106283363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970002687Medicare PIN