Provider Demographics
NPI:1679790695
Name:SMITH, WALTER DEVIN (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:DEVIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 E MCANDREWS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-776-0821
Mailing Address - Fax:541-776-5011
Practice Address - Street 1:1744 E MCANDREWS RD
Practice Address - Street 2:SUITE B
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-776-0821
Practice Address - Fax:541-776-5011
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR099000666RN163WP0808X
OR200750133NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health