Provider Demographics
NPI:1902231830
Name:SMITH, WILLIE W III (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:W
Last Name:SMITH
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:176 DAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9302
Mailing Address - Country:US
Mailing Address - Phone:304-647-4411
Mailing Address - Fax:304-793-5643
Practice Address - Street 1:1521 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8026
Practice Address - Country:US
Practice Address - Phone:304-647-5642
Practice Address - Fax:304-793-5643
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV01526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant