Provider Demographics
NPI:1659334514
Name:SMITH, LOREN E II (PA-C)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:E
Last Name:SMITH
Suffix:II
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 1:30713 HIGHWAY BB
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-8255
Mailing Address - Country:US
Mailing Address - Phone:417-532-7045
Mailing Address - Fax:
Practice Address - Street 1:341 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9217
Practice Address - Country:US
Practice Address - Phone:417-532-7850
Practice Address - Fax:417-532-2451
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-002369363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q67040Medicare UPIN