Basic Information
| Provider Information | |||||||||
| NPI: | 1750713798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LEATHA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 OAK PARK BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374944900 | ||||||||
| FaxNumber: | 3374944936 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 OAK PARK BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374944900 | ||||||||
| FaxNumber: | 3374944936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2013 | ||||||||
| LastUpdateDate: | 08/05/2013 | ||||||||
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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 | 363A00000X | PA200643 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.