Basic Information
| Provider Information | |||||||||
| NPI: | 1700826328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602598 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1238 HUFFMAN MILL RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365387050 | ||||||||
| FaxNumber: | 3365387411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 01/28/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-01842 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8101203 | 05 | NC | MEDICAID |