Healthcare Provider Details

I. General information

NPI: 1619343639
Provider Name (Legal Business Name): ADAM CLARK SMITH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 HUFFMAN MILL RD
BURLINGTON NC
27215-8700
US

IV. Provider business mailing address

PO BOX 271647
SALT LAKE CITY UT
84127-1647
US

V. Phone/Fax

Practice location:
  • Phone: 336-538-7000
  • Fax:
Mailing address:
  • Phone: 919-966-5136
  • Fax: 984-974-4873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number232507
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5245
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: