Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | RN-140291 | GA |
NPI | 1003117680 |
---|---|
Provider Name | Mr. Robert Scott Smith |
First Address | Augusta, GA 30901-2602 |
Second Address | Augusta, GA 30912-0004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/11/2010 |
Last Update Date | 17/11/2010 |