Provider Demographics
NPI:1326254046
Name:SMITH, LISA JEFFUS (PA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JEFFUS
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JEFFUS
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1624 MAIN STREET AGAPE SENIOR PRIMARY CARE, INC.
Mailing Address - Street 2:DBA AGAPE PHYSICIANS CARE
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201
Mailing Address - Country:US
Mailing Address - Phone:803-454-0365
Mailing Address - Fax:803-404-6000
Practice Address - Street 1:1761 PINEWOOD ROAD
Practice Address - Street 2:AGAPE PHYSICIANS CARE
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29154
Practice Address - Country:US
Practice Address - Phone:803-481-8591
Practice Address - Fax:855-886-9360
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000182363AM0700X
SC1307363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2764832Medicare ID - Type Unspecified