Healthcare Provider Details

I. General information

NPI: 1275725426
Provider Name (Legal Business Name): THOMAS SAMUEL SMITH FNP-BC, CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 N ALMA SCHOOL RD STE 120
MESA AZ
85201-3003
US

IV. Provider business mailing address

PO BOX 85220
TUCSON AZ
85754-5220
US

V. Phone/Fax

Practice location:
  • Phone: 480-924-8382
  • Fax:
Mailing address:
  • Phone: 520-777-4470
  • Fax: 520-777-4470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN086656
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4059
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: