Provider Demographics
NPI:1083731772
Name:SMITH, ELLEN ANDERSON (PA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:ANDERSON
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14093 ROARING FORK CIR
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-3924
Mailing Address - Country:US
Mailing Address - Phone:303-465-0876
Mailing Address - Fax:
Practice Address - Street 1:14093 ROARING FORK CIR
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-3924
Practice Address - Country:US
Practice Address - Phone:303-465-0876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO378363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCL8148Medicare PIN