Provider Demographics
NPI:1831122506
Name:SMITH, CHARLOTTE RENEE (PA)
Entity Type:Individual
Prefix:MISS
First Name:CHARLOTTE
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:RENEE
Other - Last Name:MEWBORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:P.O. BOX 84052
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-4052
Mailing Address - Country:US
Mailing Address - Phone:706-243-3051
Mailing Address - Fax:706-243-2027
Practice Address - Street 1:3465 D MACON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-2582
Practice Address - Country:US
Practice Address - Phone:706-243-3051
Practice Address - Fax:706-243-2027
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA093050990AMedicaid
GA97WCDRTMedicare ID - Type Unspecified
GA093050990AMedicaid
GAP60464Medicare UPIN