Provider Demographics
NPI:1205106036
Name:SMITH, JOHN DIXON (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DIXON
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 SHERATON BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1359
Mailing Address - Country:US
Mailing Address - Phone:478-745-5779
Mailing Address - Fax:
Practice Address - Street 1:275 SHERATON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1359
Practice Address - Country:US
Practice Address - Phone:478-745-5779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant