Healthcare Provider Details

I. General information

NPI: 1073514394
Provider Name (Legal Business Name): DAN C SMITH JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 MEMORIAL PARK DR
SPARTA NC
28675-9665
US

IV. Provider business mailing address

2230 MEMORIAL PARK DR
SPARTA NC
28675-9665
US

V. Phone/Fax

Practice location:
  • Phone: 336-372-5897
  • Fax:
Mailing address:
  • Phone: 336-372-5897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number022878
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: