Healthcare Provider Details

I. General information

NPI: 1255707675
Provider Name (Legal Business Name): CHANCE E SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 02/04/2024
Certification Date: 02/04/2024
Deactivation Date: 12/10/2021
Reactivation Date: 09/08/2023

III. Provider practice location address

3455 SW US VETERANS HOSPITAL RD
PORTLAND OR
97239-3076
US

IV. Provider business mailing address

3455 SW US VETERANS HOSPITAL RD
PORTLAND OR
97239-3076
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-7725
  • Fax:
Mailing address:
  • Phone: 650-773-1626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number201905006RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: