Basic Information
Provider Information | |||||||||
NPI: | 1487101531 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | JEREME | ||||||||
MiddleName: | STEPHEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 22487 | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543052487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204457226 | ||||||||
FaxNumber: | 9204457289 | ||||||||
Practice Location | |||||||||
Address1: | 440 WOODWARD AVE | ||||||||
Address2: |   | ||||||||
City: | IRON MOUNTAIN | ||||||||
State: | MI | ||||||||
PostalCode: | 498014631 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9067769040 | ||||||||
FaxNumber: | 9067745950 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2016 | ||||||||
LastUpdateDate: | 03/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601007871 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1137621 | 01 |   | NATIONAL COMMISSION ON CERTIFIED PHYSICIANS ASSISTANTS | OTHER | 4679-23 | 01 | WI | WISCONSIN DRL LICENSE | OTHER |