Provider Demographics
NPI:1972509446
Name:SMEDSRUD, SHELLEY R (PA)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:R
Last Name:SMEDSRUD
Suffix:
Gender:F
Credentials:PA
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 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9556
Mailing Address - Fax:605-328-9501
Practice Address - Street 1:900 E 54TH ST N STE 200
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-0686
Practice Address - Country:US
Practice Address - Phone:605-328-9556
Practice Address - Fax:605-328-9501
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0415363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6826788Medicaid
SD970029999Medicare PIN
SDS88579Medicare UPIN
SD6826788Medicaid
SD970030000Medicare PIN
SDS40876Medicare PIN