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General NPI Number Information
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NPI Number | 1275998098
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Entity Type | Individual
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Provider Name | JOSEPH SMITH PHD, ATC
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Gender | Male
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Dates
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Enumeration Date | 12/21/2015
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Last Update Date | 08/09/2021
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Provider Practice Location Address
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Address Line | 107 RAMONA RD
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City | PORTOLA VALLEY
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State | CA
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Zip | 94028-8135
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Country | US
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Telephone | 808-341-7262
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Fax |
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Provider Business Mailing Address
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Address Line | 6238 14TH ST S
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City | FARGO
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State | ND
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Zip | 58104-7230
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 04042217
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License Number State | CA
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