Provider Demographics
NPI:1245535632
Name:SMITH, COLLEEN E (PA-C)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:E
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:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-944-8910
Mailing Address - Fax:
Practice Address - Street 1:551 E HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1417
Practice Address - Country:US
Practice Address - Phone:509-944-8910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-17
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60197705363AM0700X
WA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1095451OtherPA CERTIFICATE
WAPA60197705OtherSTATE LICENSE