Provider Demographics
NPI:1659371623
Name:SMITH, CAROL ANN (PA C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:KUTNEY SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6800 LAKE DRIVE
Mailing Address - Street 2:STE 250
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-2504
Mailing Address - Country:US
Mailing Address - Phone:515-875-9925
Mailing Address - Fax:515-875-9923
Practice Address - Street 1:5950 UNIVERSITY AVENUE
Practice Address - Street 2:STE 221
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266
Practice Address - Country:US
Practice Address - Phone:515-875-9115
Practice Address - Fax:515-875-9117
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2011-09-19
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IA1013363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0634816Medicaid
IA163481Medicare ID - Type Unspecified
IA0634816Medicaid