Provider Demographics
NPI:1417931395
Name:SMITH, MARGUERITE JEAN (ANP)
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0069
Mailing Address - Country:US
Mailing Address - Phone:541-779-5877
Mailing Address - Fax:541-664-3287
Practice Address - Street 1:33 N CENTRAL AVE
Practice Address - Street 2:SUITE 425
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-5900
Practice Address - Country:US
Practice Address - Phone:541-779-5877
Practice Address - Fax:541-664-3287
Is Sole Proprietor?:No
Enumeration Date:2005-12-03
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR79042695363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276809Medicaid
OR276809Medicaid
OR135092Medicare ID - Type Unspecified