Healthcare Provider Details

I. General information

NPI: 1073630711
Provider Name (Legal Business Name): VICKI P. SMYTHE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 ECLIPSE CTR
BELOIT WI
53511-3550
US

IV. Provider business mailing address

819 N GARFIELD AVE
JANESVILLE WI
53545-1842
US

V. Phone/Fax

Practice location:
  • Phone: 608-361-0311
  • Fax: 608-361-0312
Mailing address:
  • Phone:
  • Fax: 608-756-8488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1209-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: