Healthcare Provider Details

I. General information

NPI: 1073407441
Provider Name (Legal Business Name): ANTOINE SMYRE PRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 N ADAMS ST
RICHMOND VA
23220-3903
US

IV. Provider business mailing address

3819 HARROW DR
CHESTER VA
23831-7146
US

V. Phone/Fax

Practice location:
  • Phone: 804-940-9445
  • Fax:
Mailing address:
  • Phone: 804-940-9445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0735001300
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: