MEDICARE: HEATHER SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	1332	MN

General Provider Information

NPI Number	:	1992038236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER SMITH

Provider Business Mailing Address
First Line	:	4725 36TH AVE N
Second Line	:
City	:	CRYSTAL
State	:	MN
Zip	:	55422-2169
Country	:	US
Telephone Number	:	763-231-8700
Fax Number	:	763-231-8711

Provider Business Practice Location Address
First Line	:	4725 36TH AVE N
Second Line	:
City	:	CRYSTAL
State	:	MN
Zip	:	55422-2169
Country	:	US
Telephone Number	:	763-231-8700
Fax Number	:	763-231-8711

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2009
Last Update Date	:	12/14/2011

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Directions to “ HEATHER SMITH ” Practice Location

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