Provider Demographics
NPI:1316043227
Name:SMITH, AMANDA S (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5358
Mailing Address - Country:US
Mailing Address - Phone:912-490-8546
Mailing Address - Fax:877-221-0052
Practice Address - Street 1:700 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5358
Practice Address - Country:US
Practice Address - Phone:912-490-8546
Practice Address - Fax:877-221-0052
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103832363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292817500Medicaid
GA003130352CMedicaid
GA003130352CMedicaid
FLAB7172Medicare PIN