Provider Demographics
NPI:1649280892
Name:SMITH, SANDRA BELLAMY (PA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:BELLAMY
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 1:5604 MUM CREEK LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4810
Mailing Address - Country:US
Mailing Address - Phone:843-450-2242
Mailing Address - Fax:
Practice Address - Street 1:6650 RAMSEY ST
Practice Address - Street 2:TCHS-GOODYEAR
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-9318
Practice Address - Country:US
Practice Address - Phone:803-630-5203
Practice Address - Fax:910-630-5289
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1106363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical