Basic Information
Provider Information | |||||||||
NPI: | 1750520664 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | CARRIE | ||||||||
MiddleName: | RAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1850 W ARLINGTON BLVD | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278345704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2527526101 | ||||||||
FaxNumber: | 2527526600 | ||||||||
Practice Location | |||||||||
Address1: | 3681 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FARMVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278281464 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2527537141 | ||||||||
FaxNumber: | 2527535834 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/17/2009 | ||||||||
LastUpdateDate: | 06/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0010-01679 | NC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0010-01679 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 19BFW | 01 | NC | BCBS NC | OTHER | 1750520664 | 05 | NC |   | MEDICAID |