Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 200250149NP FNP-PP | OR |
NPI | 1003127515 |
---|---|
Provider Name | Ms. Susan Irene Smith |
First Address | Portland, OR 97239-6102 |
Second Address | Portland, OR 97239-6102 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2010 |
Last Update Date | 23/01/2013 |