Provider Demographics
NPI:1255477659
Name:SMITH, BRIAN MATTHEW (RN)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MATTHEW
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 1:1621 SHASTA ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2223
Mailing Address - Country:US
Mailing Address - Phone:208-238-3229
Mailing Address - Fax:
Practice Address - Street 1:444 HOSPITAL WAY
Practice Address - Street 2:SUITE 801
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2745
Practice Address - Country:US
Practice Address - Phone:208-232-6214
Practice Address - Fax:208-233-3416
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN34646163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse