MEDICARE: SHANE RAY SMITH FNP-C

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	363L00000X	Nurse Practitioner	300208	AZ

General Provider Information

NPI Number	:	1326721796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE RAY SMITH FNP-C

Provider Business Mailing Address
First Line	:	21735 N 119TH DR
Second Line	:
City	:	SUN CITY
State	:	AZ
Zip	:	85373-5650
Country	:	US
Telephone Number	:	623-628-1522
Fax Number	:

Provider Business Practice Location Address
First Line	:	10230 W HAPPY VALLEY PKWY
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85383-4691
Country	:	US
Telephone Number	:	623-561-3030
Fax Number	:

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

Provider Enumeration Date	:	08/10/2023
Last Update Date	:	11/15/2023

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