Provider Demographics
NPI:1073514394
Name:SMITH, DAN C JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:C
Last Name:SMITH
Suffix:JR
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 1:2230 MEMORIAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NC
Mailing Address - Zip Code:28675-9665
Mailing Address - Country:US
Mailing Address - Phone:336-372-5897
Mailing Address - Fax:
Practice Address - Street 1:2230 MEMORIAL PARK DR
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675-9665
Practice Address - Country:US
Practice Address - Phone:336-372-5897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC022878367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2616937Medicare ID - Type Unspecified