Healthcare Provider Details

I. General information

NPI: 1194255950
Provider Name (Legal Business Name): GREG D SMITH APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 BLACK OAK DR
MEDFORD OR
97504
US

IV. Provider business mailing address

2620 E BARNETT RD STE H
MEDFORD OR
97504-8383
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-8176
  • Fax:
Mailing address:
  • Phone: 541-789-8176
  • Fax: 541-789-2558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number7702-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201902885NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: