Provider Demographics
NPI:1750520664
Name:SMITH, CARRIE RAE (PA)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:RAE
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 1:1850 W ARLINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5704
Mailing Address - Country:US
Mailing Address - Phone:252-752-6101
Mailing Address - Fax:252-752-6600
Practice Address - Street 1:3681 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828-1464
Practice Address - Country:US
Practice Address - Phone:252-753-7141
Practice Address - Fax:252-753-5834
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01679363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19BFWOtherBCBS NC
NC1750520664Medicaid
NC1750520664Medicaid