Provider Demographics
NPI:1790990844
Name:SMITH, BRENTLY TED (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRENTLY
Middle Name:TED
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 1:2416 CAPSTONE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2795
Mailing Address - Country:US
Mailing Address - Phone:706-327-1281
Mailing Address - Fax:706-576-9714
Practice Address - Street 1:2416 CAPSTONE CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2795
Practice Address - Country:US
Practice Address - Phone:706-327-1281
Practice Address - Fax:706-576-9714
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA05052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5052OtherGA. MEDICAL LICENSE