Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | C6469 | AR |
NPI | 1023122413 |
---|---|
Provider Name | Mark M Smith |
First Address | Jonesboro, AR 72404-6919 |
Second Address | Jonesboro, AR 72401-3119 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D17105 | (02) | AR |