Provider Demographics
NPI:1114481546
Name:SMITH PROFFITT, BREA (PAC)
Entity Type:Individual
Prefix:
First Name:BREA
Middle Name:
Last Name:SMITH PROFFITT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 GRUNDMAN BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEBRASKA CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68410-3320
Mailing Address - Country:US
Mailing Address - Phone:402-873-4242
Mailing Address - Fax:
Practice Address - Street 1:1301 GRUNDMAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:NEBRASKA CITY
Practice Address - State:NE
Practice Address - Zip Code:68410-3320
Practice Address - Country:US
Practice Address - Phone:402-873-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2318363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical