Provider Demographics
NPI:1235804212
Name:SMITH, MICHAEL ALAN (RN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 PARK PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:IOWA PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76367-1136
Mailing Address - Country:US
Mailing Address - Phone:817-925-0251
Mailing Address - Fax:
Practice Address - Street 1:100 N AVENUE D
Practice Address - Street 2:
Practice Address - City:BURKBURNETT
Practice Address - State:TX
Practice Address - Zip Code:76354-3509
Practice Address - Country:US
Practice Address - Phone:940-569-3381
Practice Address - Fax:940-569-2499
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX869768163WN0003X, 163WP0200X, 163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX869768OtherTEXAS BOARD OF NURSING