Provider Demographics
NPI:1518450915
Name:SMITH, COLLEEN GLEASON (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:GLEASON
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MARIE
Other - Last Name:GLEASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:FROEDTERT & MEDICAL COLLEGE PRE-OP CLINIC
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6250
Mailing Address - Fax:414-805-7210
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:FROEDTERT & MEDICAL COLLEGE PRE-OP CLINIC
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6250
Practice Address - Fax:414-805-7210
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4367-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1518450915Medicaid