=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689998320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHANAEL S SMITH ATC, CSCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2010
-----------------------------------------------------
Last Update Date | 02/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2420 COMANCHE RD NE SUITE G1
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-4753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-554-2315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 817 DELAMAR AVE NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-5121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-921-3518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 596
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------