Healthcare Provider Details

I. General information

NPI: 1013399336
Provider Name (Legal Business Name): JUSTIN TODD SMITH CRNA, DMPNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 VALLEY DR
POINT PLEASANT WV
25550-2031
US

IV. Provider business mailing address

20 BOSTON CMNS
WINFIELD WV
25213-9100
US

V. Phone/Fax

Practice location:
  • Phone: 304-720-8816
  • Fax: 904-494-6467
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number82829
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: