Provider Demographics
NPI:1437644689
Name:SMITH, WAYNE RANDOLPH (HT)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:RANDOLPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:HT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 WEYBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 HILL RD STE C
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4338
Practice Address - Country:US
Practice Address - Phone:415-209-6076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL25226246RH0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RH0600XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyHistology