Healthcare Provider Details

I. General information

NPI: 1598015828
Provider Name (Legal Business Name): JUSTIN SMITH CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 CHURCH ST
CONWAY SC
29526-4128
US

IV. Provider business mailing address

2001 MEDICAL PARKWAY
ANNAPOLIS MD
21401
US

V. Phone/Fax

Practice location:
  • Phone: 843-248-6269
  • Fax:
Mailing address:
  • Phone: 443-481-1366
  • Fax: 443-481-1370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR157238
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: