Provider Demographics
NPI:1003819707
Name:SMITH, MICHAEL DAVID (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2093
Mailing Address - Fax:423-390-3340
Practice Address - Street 1:3019 PEOPLES ST # CONDO300
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-1977
Practice Address - Country:US
Practice Address - Phone:423-461-2100
Practice Address - Fax:423-461-2199
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN7641363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3347731Medicaid
TNAPN7641OtherADVANCED PRACTICE NURSE
TNRN115963OtherREGISTER NURSE LICENSE
TNRN115963OtherREGISTER NURSE LICENSE
TNAPN7641OtherADVANCED PRACTICE NURSE