Provider Demographics
NPI:1871895995
Name:SMITH, A THEODORE (PA-C, LAC)
Entity type:Individual
Prefix:MR
First Name:A
Middle Name:THEODORE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C, LAC
Other - Prefix:MR
Other - First Name:TED
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C, LAC
Mailing Address - Street 1:1600W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-1411
Mailing Address - Country:US
Mailing Address - Phone:719-546-4081
Mailing Address - Fax:
Practice Address - Street 1:1600 WEST 24TH STREET
Practice Address - Street 2:COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003
Practice Address - Country:US
Practice Address - Phone:719-761-1486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant