Provider Demographics
NPI:1891745428
Name:SMITH, ROBERT G (FNP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 993
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95536-0993
Mailing Address - Country:US
Mailing Address - Phone:707-786-9170
Mailing Address - Fax:
Practice Address - Street 1:3306 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3120
Practice Address - Country:US
Practice Address - Phone:707-725-6101
Practice Address - Fax:707-725-2978
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN238330163W00000X
CAFNP877363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0516039OtherDEA