Provider Demographics
NPI:1326781774
Name:SMITH, JOHN ALBERT (AGCNS-BC, CMSRN-BC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ALBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:AGCNS-BC, CMSRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 OAK TRCE
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-8572
Mailing Address - Country:US
Mailing Address - Phone:850-376-7011
Mailing Address - Fax:
Practice Address - Street 1:4481 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5536
Practice Address - Country:US
Practice Address - Phone:937-713-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11011913364SA2200X, 364SG0600X, 364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology