Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | APN7641 | TN |
NPI | 1003819707 |
---|---|
Provider Name | Michael David Smith |
First Address | Kingsport, TN 37662-0009 |
Second Address | Johnson City, TN 37604-1977 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2005 |
Last Update Date | 30/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3347731 | (05) | TN |
APN7641 | ADVANCED PRACTICE NURSE (01) | TN |
MS0507890 | DEA LICENSE (01) | TN |
RN115963 | REGISTER NURSE LICENSE (01) | TN |
S66273 | (02) | TN |