=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982236824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NOAH SMITH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2020
-----------------------------------------------------
Last Update Date | 02/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1450 ALTA VISTA ST
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52001-4327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-258-2520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 5TH ST SW
-----------------------------------------------------
City | FARLEY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52046-9527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-258-2520
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------