Provider Demographics
NPI:1720087133
Name:SMITH, JULIAN KEVIN (PA)
Entity Type:Individual
Prefix:
First Name:JULIAN
Middle Name:KEVIN
Last Name:SMITH
Suffix:
Gender:M
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:PO BOX 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:
Practice Address - Street 1:2196 NC HIGHWAY 42 W
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-8343
Practice Address - Country:US
Practice Address - Phone:919-220-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02198363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC3700AMedicare PIN
SC0062PAMedicaid
SCP60725Medicare UPIN