Provider Demographics
NPI:1750713798
Name:SMITH, LEATHA MICHELLE (PA)
Entity type:Individual
Prefix:
First Name:LEATHA
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1717 OAK PARK BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8990
Mailing Address - Country:US
Mailing Address - Phone:337-494-4900
Mailing Address - Fax:337-494-4936
Practice Address - Street 1:1717 OAK PARK BLVD FL 3
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8990
Practice Address - Country:US
Practice Address - Phone:337-494-4900
Practice Address - Fax:337-494-4936
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAPA200643363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant