Provider Demographics
NPI:1174590590
Name:SMITH, HAROLD TRUETT JR (PA)
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:TRUETT
Last Name:SMITH
Suffix:JR
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10030 EDISON SQUARE DR NW
Practice Address - Street 2:STE 100
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-8308
Practice Address - Country:US
Practice Address - Phone:704-403-7830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101221363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1174590590Medicaid
NC8101166Medicaid
SC2299PAMedicaid
NCNC0972KMedicare PIN
NCNC0972MMedicare PIN
NCNC0972AMedicare PIN
NCNC0972EMedicare PIN
NCNC0972DMedicare PIN
NCNC0972HMedicare PIN
SC2299PAMedicaid
NCNC0972OMedicare PIN
NCNCK5510386Medicare PIN
NCS57603Medicare UPIN
NCNC0972LMedicare PIN
NCNC0972PMedicare PIN
NCNC0972IMedicare PIN
NCNC0972FMedicare PIN
NC8101166Medicaid
NCNC0972NMedicare PIN
NCNC0972UMedicare PIN
NCNC0972BMedicare PIN
NCNC0972GMedicare PIN
NCNC0972QMedicare PIN