Provider Demographics
NPI:1598135832
Name:SMITH, MICHAEL SHANE (APRN NP-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:SMITH
Suffix:
Gender:M
Credentials:APRN NP-C
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:SHANE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 1908
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75403-1908
Mailing Address - Country:US
Mailing Address - Phone:903-454-3025
Mailing Address - Fax:903-450-1408
Practice Address - Street 1:3005 JOE RAMSEY BLVD E STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-7776
Practice Address - Country:US
Practice Address - Phone:903-455-4458
Practice Address - Fax:903-455-1604
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129170363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner