Provider Demographics
NPI:1679183909
Name:SMOCK, SKYE
Entity Type:Individual
Prefix:
First Name:SKYE
Middle Name:
Last Name:SMOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 WEIMER RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6201
Mailing Address - Country:US
Mailing Address - Phone:575-758-8651
Mailing Address - Fax:
Practice Address - Street 1:1393 WEIMER RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6201
Practice Address - Country:US
Practice Address - Phone:575-758-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO363A00000X
NM363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant