Organization
RADIANT
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TIFFANY SMITH PA-C (PRESIDENT)
(304) 687-4204
Entity
Organization
Contact information
Practice address
2301 TERRA CROSSING BLVD, STE 103, LOUISVILLE, KY 40245-4994
(304) 687-4204
Mailing address
2301 TERRA CROSSING BLVD STE 103, LOUISVILLE, KY 40245-3909
(502) 410-0191
(502) 890-5177
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
22964
KY
363A00000X
Physician Assistant
PA1075
KY
363LF0000X
Family Nurse Practitioner
3007017
KY
Other
Enumeration date
01/04/2016
Last updated
10/03/2022
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