Provider Demographics
NPI:1689996613
Name:SMITH, ERICH WAVERLY (PA-C)
Entity Type:Individual
Prefix:
First Name:ERICH
Middle Name:WAVERLY
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 1:2154 SUTTON HOOTEN LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:NC
Mailing Address - Zip Code:28551-8252
Mailing Address - Country:US
Mailing Address - Phone:252-566-3298
Mailing Address - Fax:252-566-2829
Practice Address - Street 1:2154 SUTTON HOOTEN LN
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:NC
Practice Address - Zip Code:28551-8252
Practice Address - Country:US
Practice Address - Phone:252-566-3298
Practice Address - Fax:252-566-2829
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102048363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC102048OtherMEDICAL BOARD LICENSE