Provider Demographics
NPI:1619921640
Name:SMITH, ALLYSON (PA)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:
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 1:631 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 360
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3367
Mailing Address - Country:US
Mailing Address - Phone:770-962-4895
Mailing Address - Fax:770-962-4508
Practice Address - Street 1:631 PROFESSIONAL DR
Practice Address - Street 2:SUITE 360
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3367
Practice Address - Country:US
Practice Address - Phone:770-962-4895
Practice Address - Fax:770-962-4508
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103814363A00000X
GA5389363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P96311Medicare UPIN
GA511I970499Medicare PIN