Healthcare Provider Details

I. General information

NPI: 1689998320
Provider Name (Legal Business Name): NATHANAEL S SMITH ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2010
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 COMANCHE RD NE SUITE G1
ALBUQUERQUE NM
87107-4753
US

IV. Provider business mailing address

817 DELAMAR AVE NW
ALBUQUERQUE NM
87107-5121
US

V. Phone/Fax

Practice location:
  • Phone: 505-554-2315
  • Fax:
Mailing address:
  • Phone: 575-921-3518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number596
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: