Provider Demographics
NPI:1588761563
Name:SMYTH, BLAISE E (PA-C)
Entity type:Individual
Prefix:MR
First Name:BLAISE
Middle Name:E
Last Name:SMYTH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:BLAISE
Other - Middle Name:E
Other - Last Name:SMYTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:99 E RIVER DR FL 5
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-7301
Mailing Address - Country:US
Mailing Address - Phone:860-282-0833
Mailing Address - Fax:860-282-0170
Practice Address - Street 1:31 SEYMOUR STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-430-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000732363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P33110Medicare UPIN
CT970000799Medicare ID - Type Unspecified