Provider Demographics
NPI:1124016951
Name:SMITH, PATRICK KELLY (PAC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:KELLY
Last Name:SMITH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20200 54TH AVE W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6318
Mailing Address - Country:US
Mailing Address - Phone:425-672-6400
Mailing Address - Fax:
Practice Address - Street 1:20200 54TH AVE W
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6318
Practice Address - Country:US
Practice Address - Phone:425-672-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004116207P00000X, 363A00000X
WAPA60940050363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
142901OtherGREAT LAKES HEALTH PLAN
381908328OtherTRICARE
MI201OtherCOMMUNITY CHOICE OF MI
MI3381330OtherMOLINA HEALTH CARE
Q05478Medicare UPIN
142901OtherGREAT LAKES HEALTH PLAN
MIM93030P09Medicare ID - Type Unspecified
MI3381330OtherMOLINA HEALTH CARE