Provider Demographics
NPI:1588662506
Name:SMITH, MASON WILLIAMS (PA)
Entity Type:Individual
Prefix:MR
First Name:MASON
Middle Name:WILLIAMS
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BARFIELD DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-0410
Mailing Address - Country:US
Mailing Address - Phone:478-237-8342
Mailing Address - Fax:478-237-8281
Practice Address - Street 1:131A VICTORY DR
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3234
Practice Address - Country:US
Practice Address - Phone:478-237-8342
Practice Address - Fax:478-237-8281
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH011423183500000X
GA000305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001353AMedicaid
GA10047407OtherAMERIGROUP
P44912Medicare UPIN
GA97WCCHVMedicare ID - Type Unspecified