Healthcare Provider Details

I. General information

NPI: 1720571623
Provider Name (Legal Business Name): COLTON DAVIS SMITH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 KIMEL PARK DR STE 120
WINSTON SALEM NC
27103-6983
US

IV. Provider business mailing address

145 KIMEL PARK DR STE 120
WINSTON SALEM NC
27103-6983
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-3212
  • Fax: 336-768-9019
Mailing address:
  • Phone: 336-768-3212
  • Fax: 336-768-9019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number268232
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: