Provider Demographics
NPI:1336506658
Name:SMITH, THEODORE C (CRNA)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:T.C.
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:622 W LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-5571
Mailing Address - Country:US
Mailing Address - Phone:801-698-4825
Mailing Address - Fax:
Practice Address - Street 1:2055 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9819
Practice Address - Country:US
Practice Address - Phone:801-698-4825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-16
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28227009A163W00000X
UT7570542-3102163W00000X
FL9369122163W00000X
UT7570542-4406367500000X
IN288227009A367500000X
MT143224367500000X
UT7570542-8901367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse