Basic Information
| Provider Information | |||||||||
| NPI: | 1891053872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | COOPER | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1490 | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286071490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282647311 | ||||||||
| FaxNumber: | 8282647907 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 HIGHWAY 105 EXT STE 100 | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286074291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282647311 | ||||||||
| FaxNumber: | 8282647907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2012 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 0010-03378 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 0010-03378 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 0010-03378 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.