Provider Demographics
NPI:1073381984
Name:SMITH, JOHN ANDREW (RN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:ANDREW
Other - Last Name:PENA
Other - Suffix:III
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3396 S JOSHUA TREE LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3396 S JOSHUA TREE LN
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7854
Practice Address - Country:US
Practice Address - Phone:480-865-7517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ220888163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse