Healthcare Provider Details

I. General information

NPI: 1871592709
Provider Name (Legal Business Name): BRIAN K SMITH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 03/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N LINCOLN AVE
MONETT MO
65708-1641
US

IV. Provider business mailing address

PO BOX 4046
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-235-3144
  • Fax: 417-354-1177
Mailing address:
  • Phone: 417-269-5712
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2012025986
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: