Provider Demographics
NPI:1326721796
Name:SMITH, SHANE RAY (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:RAY
Last Name:SMITH
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21735 N 119TH DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85373-5650
Mailing Address - Country:US
Mailing Address - Phone:623-628-1522
Mailing Address - Fax:
Practice Address - Street 1:10230 W HAPPY VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-4691
Practice Address - Country:US
Practice Address - Phone:623-561-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ300208363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner