Provider Demographics
NPI:1689998320
Name:SMITH, NATHANAEL S (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:S
Last Name:SMITH
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 DELAMAR AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5121
Mailing Address - Country:US
Mailing Address - Phone:575-921-3518
Mailing Address - Fax:
Practice Address - Street 1:2420 COMANCHE RD NE
Practice Address - Street 2:SUITE G1
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4753
Practice Address - Country:US
Practice Address - Phone:505-554-2315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer