Provider Demographics
NPI:1619750320
Name:SMITH, PHILIP JASON (FNP)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:JASON
Last Name:SMITH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13530 FM 1661
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:TX
Mailing Address - Zip Code:79553-7012
Mailing Address - Country:US
Mailing Address - Phone:325-513-4404
Mailing Address - Fax:
Practice Address - Street 1:1 AVENUE N
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:TX
Practice Address - Zip Code:79521-5415
Practice Address - Country:US
Practice Address - Phone:940-353-6603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1131807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily