Basic Information
| Provider Information | |||||||||
| NPI: | 1598135832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SHANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | SHANE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1908 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754031908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034543025 | ||||||||
| FaxNumber: | 9034501408 | ||||||||
| Practice Location | |||||||||
| Address1: | 3005 JOE RAMSEY BLVD E STE A | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754017776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034554458 | ||||||||
| FaxNumber: | 9034551604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2015 | ||||||||
| LastUpdateDate: | 10/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP129170 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.