Provider Demographics
NPI:1790173623
Name:SMITH, JUSTIN NORWOOD (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:NORWOOD
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 1:1101 WOODS CT
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-9643
Mailing Address - Country:US
Mailing Address - Phone:910-398-0341
Mailing Address - Fax:
Practice Address - Street 1:611 N 35TH ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-3126
Practice Address - Country:US
Practice Address - Phone:252-222-5700
Practice Address - Fax:252-222-5705
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05447363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant