Provider Demographics
NPI:1114011905
Name:SMITH, MATTHEW A (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
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 268
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0268
Mailing Address - Country:US
Mailing Address - Phone:801-296-2113
Mailing Address - Fax:801-296-1715
Practice Address - Street 1:2055 N MAIN ST.
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-843-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX722182367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86048UOtherHMO BLUE
TX147826101OtherFIRSTCARE COMMERCIAL
TX67417Medicaid
TX86049UOtherBC/BS
TX147826100Medicaid
OK200074480AMedicaid
NM202004760OtherPRESBYTERIAN COMMERCIAL
NM202004760Medicaid
UT1114011905Medicaid
TX180263901Medicaid
NM42324777Medicaid
TX86049UOtherBC/BS
OK200074480AMedicaid