Provider Demographics
NPI:1093974552
Name:SMITH, MARK A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:SMITH
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:2420 E PIKES PEAK AVE
Mailing Address - Street 2:SUITE 1044
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-6005
Mailing Address - Country:US
Mailing Address - Phone:719-365-6692
Mailing Address - Fax:719-365-5004
Practice Address - Street 1:8540 SCARBOROUGH DR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7502
Practice Address - Country:US
Practice Address - Phone:719-955-4200
Practice Address - Fax:719-955-4201
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2014-06-12
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Provider Licenses
StateLicense IDTaxonomies
COPA-3348363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3348OtherCOLORADO PA STATE LICENSE