Provider Demographics
NPI:1043652118
Name:SMITH, CHRISTINA DICARLO (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:DICARLO
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:
Other - Last Name:DICARLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1004 ASHMORE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-5956
Mailing Address - Country:US
Mailing Address - Phone:678-986-7500
Mailing Address - Fax:
Practice Address - Street 1:1010 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-3733
Practice Address - Country:US
Practice Address - Phone:864-537-0159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
SCTL1969363A00000X
SC1969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1709PAMedicaid
SCSC19795019Medicare PIN
SCSC19796067Medicare PIN