Provider Demographics
NPI:1043652118
Name:SMITH, CHRISTINA DICARLO (PA)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:DICARLO
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:
Other - Last Name:DICARLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 749306
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9306
Mailing Address - Country:US
Mailing Address - Phone:678-986-7500
Mailing Address - Fax:
Practice Address - Street 1:35 RAY E TALLEY CT
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-6772
Practice Address - Country:US
Practice Address - Phone:864-967-7028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
SCTL1969363A00000X
SC1969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1709PAMedicaid
SCSC19795019Medicare PIN
SCSC19796067Medicare PIN