Provider Demographics
NPI:1689937963
Name:SMITH, BRITTANY N (PAC)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:N
Last Name:SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:N
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:6405 FRANCE AVE S STE 200
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2164
Mailing Address - Country:US
Mailing Address - Phone:952-836-3422
Mailing Address - Fax:952-836-3950
Practice Address - Street 1:6405 FRANCE AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-836-3422
Practice Address - Fax:952-836-3950
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI363A00000X
MN12255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1689937963Medicaid
WI736012512Medicare PIN