Provider Demographics
NPI:1407132459
Name:SMITH, VICTORIA K (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:K
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 1:75 RAILROAD AVE
Mailing Address - Street 2:APT 2K
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-9204
Mailing Address - Country:US
Mailing Address - Phone:218-831-1173
Mailing Address - Fax:
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2805
Practice Address - Country:US
Practice Address - Phone:203-384-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5923363A00000X
CT002666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002666OtherPHYSICIAN ASSISTANT LICENSE