Basic Information
| Provider Information | |||||||||
| NPI: | 1629149950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 HERITAGE WAY STE 2100 | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062578992 | ||||||||
| FaxNumber: | 4062578996 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 HERITAGE WAY STE 2100 | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062578992 | ||||||||
| FaxNumber: | 4062578996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 545903 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | AP114644 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 327250YLLW | 01 | MEDICARE | OTHER | 8332NK | 01 | TX | BCBS | OTHER | 297298602 | 05 | TX | MEDICAID | 297298603 | 05 | TX | MEDICAID | 297298604 | 01 | TX | CSHCN | OTHER |