Basic Information
| Provider Information | |||||||||
| NPI: | 1093044463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEWIS | ||||||||
| OtherFirstName: | PAMELA | ||||||||
| OtherMiddleName: | MICHELE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 37090 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7032959369 | ||||||||
| Practice Location | |||||||||
| Address1: | 5818 HARBOUR VIEW BLVD | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234353315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574836100 | ||||||||
| FaxNumber: | 7032959369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2009 | ||||||||
| LastUpdateDate: | 05/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 237361 | NC | N | Nursing Service Providers | Registered Nurse | 367500000X | 0024169997 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8053790 | 05 | NC | MEDICAID |