Healthcare Provider Details

I. General information

NPI: 1518325240
Provider Name (Legal Business Name): PATRICK SMITH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 4TH ST
LONGVIEW TX
75605-5128
US

IV. Provider business mailing address

2901 4TH ST
LONGVIEW TX
75605-5128
US

V. Phone/Fax

Practice location:
  • Phone: 903-758-1818
  • Fax:
Mailing address:
  • Phone: 903-758-1818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP130017
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: