Provider Demographics
NPI:1710952585
Name:SMITH, TERRY L (PAC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
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:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-1988
Mailing Address - Country:US
Mailing Address - Phone:606-439-1300
Mailing Address - Fax:606-439-1400
Practice Address - Street 1:101 TOWN AND COUNTRY LN STE 100
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9524
Practice Address - Country:US
Practice Address - Phone:606-439-1300
Practice Address - Fax:606-439-1400
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA955363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95005930Medicaid
KY183942Medicare Oscar/Certification
KY0776313Medicare PIN
KY95005930Medicaid
KY183947Medicare Oscar/Certification
KY00051006Medicare PIN
KY183918Medicare Oscar/Certification
KY0984402Medicare PIN