Basic Information
| Provider Information | |||||||||
| NPI: | 1326254046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | JEFFUS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | JEFFUS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1624 MAIN STREET AGAPE SENIOR PRIMARY CARE, INC. | ||||||||
| Address2: | DBA AGAPE PHYSICIANS CARE | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034540365 | ||||||||
| FaxNumber: | 8034046000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1761 PINEWOOD ROAD | ||||||||
| Address2: | AGAPE PHYSICIANS CARE | ||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034818591 | ||||||||
| FaxNumber: | 8558869360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 03/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 001000182 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 1307 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.