Provider Demographics
NPI:1659809028
Name:SMITH, STEPHEN JEROME (EMT-B)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JEROME
Last Name:SMITH
Suffix:
Gender:M
Credentials:EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6131 N 27TH AVE APT 2011
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-1756
Mailing Address - Country:US
Mailing Address - Phone:228-273-7752
Mailing Address - Fax:
Practice Address - Street 1:1826 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-1612
Practice Address - Country:US
Practice Address - Phone:228-273-7752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ67133531146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic