Healthcare Provider Details

I. General information

NPI: 1124016951
Provider Name (Legal Business Name): PATRICK KELLY SMITH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20200 54TH AVE W
LYNNWOOD WA
98036-6318
US

IV. Provider business mailing address

20200 54TH AVE W
LYNNWOOD WA
98036-6318
US

V. Phone/Fax

Practice location:
  • Phone: 425-672-6400
  • Fax:
Mailing address:
  • Phone: 425-672-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601004116
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60940050
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5601004116
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: