Provider Demographics
NPI:1285631648
Name:SMITH-EDE, BOBBIE J (FNP)
Entity Type:Individual
Prefix:MRS
First Name:BOBBIE
Middle Name:J
Last Name:SMITH-EDE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 E BARNETT RD
Mailing Address - Street 2:MSS
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8332
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:541-789-4806
Practice Address - Street 1:555 BLACK OAK DRIVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8225
Practice Address - Country:US
Practice Address - Phone:541-789-8000
Practice Address - Fax:541-789-8225
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250183363L00000X
OR200250183NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100163Medicaid
ORR117804Medicare PIN
OR100163Medicaid