Provider Demographics
NPI:1629563242
Name:SMITH, MORGAN (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:MORGAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FERN OAK CIR APT 201
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-8459
Mailing Address - Country:US
Mailing Address - Phone:301-775-1552
Mailing Address - Fax:
Practice Address - Street 1:8200 MEADOWBRIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2337
Practice Address - Country:US
Practice Address - Phone:804-730-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260030012083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Single Specialty