MEDICARE: MS. DEBORAH SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA00012238	WA

General Provider Information

NPI Number	:	1194929950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DEBORAH SMITH

Provider Business Mailing Address
First Line	:	412 SW LOTUS CT
Second Line	:
City	:	PORT ORCHARD
State	:	WA
Zip	:	98367-7200
Country	:	US
Telephone Number	:	360-874-9765
Fax Number	:

Provider Business Practice Location Address
First Line	:	1008 BETHEL AVE STE A
Second Line	:
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-4236
Country	:	US
Telephone Number	:	360-509-3774
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	07/08/2007

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