Provider Demographics
NPI:1043663248
Name:SMITH, BRIELLE (PA-C)
Entity type:Individual
Prefix:
First Name:BRIELLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 LUTHERAN PKWY
Mailing Address - Street 2:SUITE 340
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6021
Mailing Address - Country:US
Mailing Address - Phone:303-996-6005
Mailing Address - Fax:
Practice Address - Street 1:3555 LUTHERAN PKWY
Practice Address - Street 2:SUITE 340
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6021
Practice Address - Country:US
Practice Address - Phone:303-996-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004700363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical