Provider Demographics
NPI:1770813651
Name:SMITH, GWEN LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 E 20TH ST
Mailing Address - Street 2:STE 700
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1049
Mailing Address - Country:US
Mailing Address - Phone:605-334-0393
Mailing Address - Fax:605-334-6028
Practice Address - Street 1:911 E 20TH ST
Practice Address - Street 2:STE 700
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1049
Practice Address - Country:US
Practice Address - Phone:605-334-0393
Practice Address - Fax:605-334-6028
Is Sole Proprietor?:No
Enumeration Date:2009-12-28
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0727363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6832920Medicaid
SD104640Medicare PIN
SDS103828Medicare PIN