Provider Demographics
NPI:1154309326
Name:SMITH, NATHAN BRYAN (PA C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:BRYAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-6019
Mailing Address - Country:US
Mailing Address - Phone:541-681-5090
Mailing Address - Fax:
Practice Address - Street 1:743 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6019
Practice Address - Country:US
Practice Address - Phone:541-681-5090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004600363A00000X
ORPA01365363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0208529OtherLDI
8941241OtherLDI
WA8379174Medicaid
Q08592Medicare UPIN
WA8379174Medicaid