Basic Information
| Provider Information | |||||||||
| NPI: | 1093974552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2420 E PIKES PEAK AVE | ||||||||
| Address2: | SUITE 1044 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809096005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193656692 | ||||||||
| FaxNumber: | 7193655004 | ||||||||
| Practice Location | |||||||||
| Address1: | 8540 SCARBOROUGH DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199554200 | ||||||||
| FaxNumber: | 7199554201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 06/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA-3348 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.