Provider Demographics
NPI:1003068628
Name:SMITH, KATIE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
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 1:32214 ELLINGWOOD TRL
Mailing Address - Street 2:SUITE #210
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-9779
Mailing Address - Country:US
Mailing Address - Phone:303-679-2020
Mailing Address - Fax:
Practice Address - Street 1:32214 ELLINGWOOD TRL
Practice Address - Street 2:SUITE #210
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-9779
Practice Address - Country:US
Practice Address - Phone:303-679-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2609363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1082610OtherNCCPA