Provider Demographics
NPI:1831304559
Name:SMITH, EVA ROSE (PA)
Entity Type:Individual
Prefix:MRS
First Name:EVA
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 OLD OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1644
Mailing Address - Country:US
Mailing Address - Phone:229-391-3500
Mailing Address - Fax:229-391-3498
Practice Address - Street 1:1948 OLD OCILLA RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1644
Practice Address - Country:US
Practice Address - Phone:229-391-3500
Practice Address - Fax:229-391-3498
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN093803363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology