Provider Demographics
NPI:1811202146
Name:SMITH, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 BELLEVUE AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1856
Mailing Address - Country:US
Mailing Address - Phone:314-977-1052
Mailing Address - Fax:314-977-1067
Practice Address - Street 1:1031 BELLEVUE AVE STE 280A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1818
Practice Address - Country:US
Practice Address - Phone:314-977-1052
Practice Address - Fax:314-977-1067
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085003909363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO43-0654872Medicaid
IL085003909Medicaid
IL988280011Medicare PIN
IL0371240002Medicare NSC