Healthcare Provider Details

I. General information

NPI: 1699318295
Provider Name (Legal Business Name): SERGEY SMIRNOV NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2019
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 RIVERTOWN SHOPS DR STE 102-161
ST JOHNS FL
32259-7506
US

IV. Provider business mailing address

6629 BROADWAY APT 5C
BRONX NY
10471-2040
US

V. Phone/Fax

Practice location:
  • Phone: 904-377-3154
  • Fax:
Mailing address:
  • Phone: 646-552-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number345197
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11005649
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: