Provider Demographics
NPI:1245204890
Name:SMITH, GREGORY A (FNP)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2955 HARRISON ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1154
Mailing Address - Country:US
Mailing Address - Phone:409-923-1650
Mailing Address - Fax:409-923-1651
Practice Address - Street 1:2955 HARRISON ST
Practice Address - Street 2:SUITE 301
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1154
Practice Address - Country:US
Practice Address - Phone:409-923-1650
Practice Address - Fax:409-923-1651
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX559394363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179210302Medicaid
TXQ48142Medicare UPIN
TX8F22576Medicare PIN