Provider Demographics
NPI:1134601180
Name:MCCREEDY, WILEY SMART (PA)
Entity type:Individual
Prefix:
First Name:WILEY
Middle Name:SMART
Last Name:MCCREEDY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2112 NW QUIMBY ST APT 542
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2380
Mailing Address - Country:US
Mailing Address - Phone:970-729-0488
Mailing Address - Fax:
Practice Address - Street 1:1 MERCADO ST STE 202
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7307
Practice Address - Country:US
Practice Address - Phone:970-764-9400
Practice Address - Fax:970-764-9449
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
COPA.0006628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant