Provider Demographics
NPI:1699101063
Name:SMITH, RYAN D (AA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:AA-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 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:303-493-7000
Mailing Address - Fax:
Practice Address - Street 1:13123 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7106
Practice Address - Country:US
Practice Address - Phone:720-777-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COANT.0000055367H00000X
MO2013034524367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid