Provider Demographics
NPI:1679749014
Name:SMITH, AMANDA LUCILLE (PAC)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:LUCILLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 HASKINS RD STE B
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1600
Mailing Address - Country:US
Mailing Address - Phone:419-373-7607
Mailing Address - Fax:419-353-7076
Practice Address - Street 1:838 E WOOSTER ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-3186
Practice Address - Country:US
Practice Address - Phone:419-372-2271
Practice Address - Fax:419-354-3222
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055640363A00000X
FLPA9104163363A00000X
OH50.005136RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0277704Medicaid
OH50.005136RXOtherOHIO MEDICAL LICENSE