Healthcare Provider Details

I. General information

NPI: 1912066556
Provider Name (Legal Business Name): THOMAS L. SMITH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 LOUISIANA AVE
SHREVEPORT LA
71101-3908
US

IV. Provider business mailing address

1806 AUDUBON PL
SHREVEPORT LA
71105-3424
US

V. Phone/Fax

Practice location:
  • Phone: 318-227-1211
  • Fax: 318-678-4185
Mailing address:
  • Phone: 318-227-1221
  • Fax: 318-678-4185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number31740
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: