Provider Demographics
NPI:1497537898
Name:SMITH, IAN MICHAEL (CPO)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 NE 136TH AVE APT 284
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5985
Mailing Address - Country:US
Mailing Address - Phone:360-907-3341
Mailing Address - Fax:
Practice Address - Street 1:1516 HUDSON ST STE 105
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3046
Practice Address - Country:US
Practice Address - Phone:360-423-6049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPO05333222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist