Provider Demographics
NPI:1548233133
Name:SMITH, RAYMOND R (RUSTY) (CRNA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:R (RUSTY)
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:RAYMOND
Other - Middle Name:R (RUSTY)
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:241 AIMEE RD
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-9615
Mailing Address - Country:US
Mailing Address - Phone:318-757-6371
Mailing Address - Fax:318-757-7847
Practice Address - Street 1:241 AIMEE RD
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-9615
Practice Address - Country:US
Practice Address - Phone:318-757-6371
Practice Address - Fax:318-757-6371
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN032208367500000X
MSR611034367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS050584209AOtherMS BLUE CROSS
MS00127016Medicaid
LA1139351Medicaid
MS050584209AOtherMS BLUE CROSS
MS00127016Medicaid
LA1139351Medicaid