Provider Demographics
NPI:1386627560
Name:SMIKAHL, TRICIA L (PA)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:L
Last Name:SMIKAHL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRICIA
Other - Middle Name:L
Other - Last Name:VONDRASEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3413
Mailing Address - Country:US
Mailing Address - Phone:970-495-7421
Mailing Address - Fax:970-493-3528
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:SUITE 170
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3413
Practice Address - Country:US
Practice Address - Phone:970-495-7421
Practice Address - Fax:970-493-3528
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2020363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95183779Medicaid
COCOA102599Medicare PIN
CO95183779Medicaid