Provider Demographics
NPI:1003909854
Name:SMITH, PERCY L JR (PA)
Entity Type:Individual
Prefix:MR
First Name:PERCY
Middle Name:L
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:PERCY
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1883 HWY 43 SOUTH, SUITE D
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046
Mailing Address - Country:US
Mailing Address - Phone:601-859-8992
Mailing Address - Fax:601-859-7642
Practice Address - Street 1:1883 HWY 43 SOUTH, SUITE D
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046
Practice Address - Country:US
Practice Address - Phone:601-859-8992
Practice Address - Fax:601-859-7642
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05475760Medicaid
MS05475760Medicaid
MS251850Medicare Oscar/Certification
MSC01051Medicare Oscar/Certification
MS970000038Medicare PIN