Basic Information
| Provider Information | |||||||||
| NPI: | 1679183909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMOCK | ||||||||
| FirstName: | SKYE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1393 WEIMER RD | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875716201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757588651 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1393 WEIMER RD | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875716201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757586851 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2020 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.