Healthcare Provider Details

I. General information

NPI: 1649643412
Provider Name (Legal Business Name): CLAYTON N SMITH JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

244 S DALLAS AVE
SAN BERNARDINO CA
92410-1964
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-1000
  • Fax:
Mailing address:
  • Phone: 903-724-6295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95035744
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95035744
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: