Provider Demographics
NPI:1134313562
Name:SMYTH, KORI ANNE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:KORI
Middle Name:ANNE
Last Name:SMYTH
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 1:5100 GATEWAY CTR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3927
Mailing Address - Country:US
Mailing Address - Phone:810-733-6480
Mailing Address - Fax:810-733-8740
Practice Address - Street 1:5100 GATEWAY CTR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3927
Practice Address - Country:US
Practice Address - Phone:810-733-6480
Practice Address - Fax:810-733-8740
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004562363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
N87110016Medicare PIN