Provider Demographics
NPI:1891053872
Name:SMITH, SHELLY COOPER (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:COOPER
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 1490
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-1490
Mailing Address - Country:US
Mailing Address - Phone:828-264-7311
Mailing Address - Fax:828-264-7907
Practice Address - Street 1:240 HIGHWAY 105 EXT STE 100
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4291
Practice Address - Country:US
Practice Address - Phone:828-264-7311
Practice Address - Fax:828-264-7907
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03378363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical