# PATRICK KELLY SMITH

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1124016951
- **Gender:** Man
- **Credential:** PAC

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207P00000X | Emergency Medicine Physician | 5601004116 | MI | — |
| 363A00000X | Physician Assistant | 5601004116 | MI | — |
| 363A00000X | Physician Assistant | PA60940050 | WA | Yes |

## Other

- **Enumeration date:** 10/06/2005
- **Last updated:** 05/05/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 142901 | GREAT LAKES HEALTH PLAN | — |
| 01 | — | 201 | COMMUNITY CHOICE OF MI | MI |
| 01 | — | 3381330 | MOLINA HEALTH CARE | MI |
| 01 | — | 381908328 | TRICARE | — |