Provider Demographics
NPI:1518010305
Name:SMITH, KIRK RANDALL (DHSC, ARNP)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:RANDALL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DHSC, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811
Mailing Address - Country:US
Mailing Address - Phone:863-499-6018
Mailing Address - Fax:863-686-8868
Practice Address - Street 1:1475 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811
Practice Address - Country:US
Practice Address - Phone:863-499-6018
Practice Address - Fax:863-686-8868
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2460782363L00000X
FLARNP2640782363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S97898Medicare UPIN