Provider Demographics
NPI:1932180668
Name:SMITH, BRETT A (PA-C)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S 3RD W
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-1559
Mailing Address - Country:US
Mailing Address - Phone:208-547-3341
Mailing Address - Fax:208-547-2790
Practice Address - Street 1:300 S 3RD W
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-1559
Practice Address - Country:US
Practice Address - Phone:208-547-3118
Practice Address - Fax:208-547-0424
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-422363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1548930878Medicaid
IDPAHH6OtherBLUE CROSS
IDP87915Medicare UPIN
ID806721500Medicaid
IDPAHH6OtherBLUE CROSS