Healthcare Provider Details

I. General information

NPI: 1598196149
Provider Name (Legal Business Name): HEIDI L SMITH PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E SUITE 101
ALEXANDRIA MN
56308-5273
US

IV. Provider business mailing address

1500 IRVING ST STE 102
ALEXANDRIA MN
56308-0047
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1144
  • Fax:
Mailing address:
  • Phone: 320-762-1144
  • Fax: 320-762-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15959
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2446
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: