Provider Demographics
NPI:1114128956
Name:SMITH, CAROLYN ANN (PA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:101 E REDLANDS BLVD
Mailing Address - Street 2:212
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4775
Mailing Address - Country:US
Mailing Address - Phone:909-335-8649
Mailing Address - Fax:909-335-1994
Practice Address - Street 1:1551 BISHOP ST
Practice Address - Street 2:220
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4635
Practice Address - Country:US
Practice Address - Phone:805-541-0668
Practice Address - Fax:805-541-8213
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2010-09-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPA14769363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABN576ZMedicare PIN
CAWPA14769BMedicare PIN