Provider Demographics
NPI:1073630711
Name:SMYTHE, VICKI P (PA-C)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:P
Last Name:SMYTHE
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 1:819 N GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:608-756-8488
Practice Address - Street 1:74 ECLIPSE CTR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3550
Practice Address - Country:US
Practice Address - Phone:608-361-0311
Practice Address - Fax:608-361-0312
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1209-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP04087Medicare UPIN