MEDICARE: WALTER JASON SMITH CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	RN185136	GA

General Provider Information

NPI Number	:	1578923355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER JASON SMITH CRNA

Provider Business Mailing Address
First Line	:	1635 OLD 41 HWY NW
Second Line	:
City	:	KENNESAW
State	:	GA
Zip	:	30152-4480
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1635 OLD 41 HWY NW
Second Line	:
City	:	KENNESAW
State	:	GA
Zip	:	30152-4480
Country	:	US
Telephone Number	:	870-530-0081
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2016
Last Update Date	:	03/07/2016

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