Provider Demographics
NPI:1407814510
Name:SMITH, RYAN KYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KYLE
Last Name:SMITH
Suffix:
Gender:M
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:PO BOX 5779
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-5779
Mailing Address - Country:US
Mailing Address - Phone:706-320-0381
Mailing Address - Fax:706-310-0390
Practice Address - Street 1:5126 HOSPITAL DR NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2566
Practice Address - Country:US
Practice Address - Phone:800-532-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004414363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ25367Medicare UPIN
GA97WCHMLMedicare ID - Type Unspecified