MEDICARE: MICAH SMITH ATC

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	2255A2300X	Athletic Trainer	10226142	OR

General Provider Information

NPI Number	:	1992257331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICAH SMITH ATC

Provider Business Mailing Address
First Line	:	411 W HAWKINS PKWY
Second Line	:	APT 4301
City	:	LONGVIEW
State	:	TX
Zip	:	75605-1723
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7325 SW CHILDS RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97224-7713
Country	:	US
Telephone Number	:	317-504-0593
Fax Number	:

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

Provider Enumeration Date	:	11/02/2016
Last Update Date	:	04/19/2024

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