Provider Demographics
NPI:1154655975
Name:SMITH, REBECCA A (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 COLE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3220
Mailing Address - Country:US
Mailing Address - Phone:303-716-8018
Mailing Address - Fax:303-763-5495
Practice Address - Street 1:13402 W COAL MINE AVE STE 300
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80127-5407
Practice Address - Country:US
Practice Address - Phone:303-963-0566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO004756878Medicaid