Provider Demographics
NPI:1639608276
Name:SMITH, CONNOR LOGAN
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:LOGAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CLARA BARTON DR # MC-164
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3472
Mailing Address - Country:US
Mailing Address - Phone:518-262-5511
Mailing Address - Fax:
Practice Address - Street 1:2 CLARA BARTON DR # MC-164
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3472
Practice Address - Country:US
Practice Address - Phone:518-262-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program