Provider Demographics
NPI:1376186064
Name:SMITH, BRENT TYLER (RN)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:TYLER
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 1:323 DANA ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-5755
Mailing Address - Country:US
Mailing Address - Phone:570-472-7283
Mailing Address - Fax:
Practice Address - Street 1:562 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3721
Practice Address - Country:US
Practice Address - Phone:570-552-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP002819363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily