Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 107558 | WV |
NPI | 1003576414 |
---|---|
Provider Name | Charles Jason Smith |
First Address | Barboursville, WV 25504-9630 |
Second Address | Huntington, WV 25705-1936 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/12/2021 |
Last Update Date | 27/12/2021 |