Healthcare Provider Details

I. General information

NPI: 1225556111
Provider Name (Legal Business Name): JAIME SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 DRY CREEK DR
LONGMONT CO
80503-6405
US

IV. Provider business mailing address

2500 E PROSPECT RD
FORT COLLINS CO
80525-9718
US

V. Phone/Fax

Practice location:
  • Phone: 303-772-1600
  • Fax: 303-772-9317
Mailing address:
  • Phone: 970-493-0112
  • Fax: 970-493-0521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0005059
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: