Provider Demographics
NPI:1013211002
Name:SMITH, SCOTT C (CRNA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
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 952248
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75395-0001
Mailing Address - Country:US
Mailing Address - Phone:201-804-2800
Mailing Address - Fax:
Practice Address - Street 1:403 BURKARTH RD
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-3101
Practice Address - Country:US
Practice Address - Phone:660-747-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000143092367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2011000121OtherLICENSE
TN085519OtherCRNA