Provider Demographics
NPI:1194820035
Name:SMITH, LESTER DEAN (PAC)
Entity Type:Individual
Prefix:
First Name:LESTER
Middle Name:DEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 CHAMBERLAIN LN STE 101
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2091
Mailing Address - Country:US
Mailing Address - Phone:502-426-9200
Mailing Address - Fax:
Practice Address - Street 1:3707 CHAMBERLAIN LN STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2091
Practice Address - Country:US
Practice Address - Phone:502-426-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95006227Medicaid
KY000000499232OtherANTHEM FACETS PIN
KY95006227Medicaid
KYP00353769Medicare PIN
KY1451832Medicare PIN