Provider Demographics
NPI:1245270248
Name:SMITH, SHERYL (PA-C)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:
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 1:1011 SUNNYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-8735
Mailing Address - Country:US
Mailing Address - Phone:231-779-2565
Mailing Address - Fax:231-775-0744
Practice Address - Street 1:1011 SUNNYSIDE DR
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-8735
Practice Address - Country:US
Practice Address - Phone:231-779-2565
Practice Address - Fax:231-775-0744
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI8450075OtherMEDICARE PTAN
MI0M74460358Medicare PIN
R57667Medicare UPIN
MI0M14760 013Medicare PIN