Provider Demographics
NPI:1669470597
Name:SMITH, DAVID J (PA-AA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 MINNEQUA AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3733
Mailing Address - Country:US
Mailing Address - Phone:719-557-4221
Mailing Address - Fax:719-557-3834
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3733
Practice Address - Country:US
Practice Address - Phone:719-557-4221
Practice Address - Fax:719-557-3834
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO880367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07008808Medicaid
S50737Medicare UPIN
184758Medicare ID - Type Unspecified
COC810001Medicare Oscar/Certification