Healthcare Provider Details

I. General information

NPI: 1003819707
Provider Name (Legal Business Name): MICHAEL DAVID SMITH NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 PEOPLES ST # CONDO300
JOHNSON CITY TN
37604-1977
US

IV. Provider business mailing address

PO BOX 9
KINGSPORT TN
37662-0009
US

V. Phone/Fax

Practice location:
  • Phone: 423-461-2100
  • Fax: 423-461-2199
Mailing address:
  • Phone: 423-857-2093
  • Fax: 423-390-3340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN7641
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN7641
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: