Provider Demographics
NPI:1265704860
Name:SMITH, VEKETA HARRIS (PA-C)
Entity type:Individual
Prefix:
First Name:VEKETA
Middle Name:HARRIS
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 1:1265 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4548
Mailing Address - Country:US
Mailing Address - Phone:678-435-3045
Mailing Address - Fax:678-435-3044
Practice Address - Street 1:1265 HIGHWAY 54 W
Practice Address - Street 2:SUITE 201
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4548
Practice Address - Country:US
Practice Address - Phone:678-435-3045
Practice Address - Fax:678-435-3044
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2245363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical