Provider Demographics
NPI:1104006592
Name:SMITH, RAYMOND SHANE (PA-C)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:SHANE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6971
Mailing Address - Country:US
Mailing Address - Phone:423-431-2477
Mailing Address - Fax:423-431-2478
Practice Address - Street 1:410 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 130
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6971
Practice Address - Country:US
Practice Address - Phone:423-431-2477
Practice Address - Fax:423-431-2478
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1104006592Medicaid
TNQ002626Medicaid
VA1104006592Medicaid
NC1104006592Medicaid
TNQ002626Medicaid