Provider Demographics
NPI:1114490687
Name:SMITH, ELIZABETH BROOKE JOHNSON (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BROOKE JOHNSON
Last Name:SMITH
Suffix:
Gender:F
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 1:225 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3109
Mailing Address - Country:US
Mailing Address - Phone:704-376-1605
Mailing Address - Fax:
Practice Address - Street 1:225 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3109
Practice Address - Country:US
Practice Address - Phone:704-376-1605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08724363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical