Provider Demographics
NPI:1942276175
Name:SMITH, WILLIAM KEN (CRNA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KEN
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5250 N OCEAN DR
Mailing Address - Street 2:#4N
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-2657
Mailing Address - Country:US
Mailing Address - Phone:561-876-5845
Mailing Address - Fax:561-370-7026
Practice Address - Street 1:5250 N OCEAN DR
Practice Address - Street 2:#4N
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-2657
Practice Address - Country:US
Practice Address - Phone:561-876-5845
Practice Address - Fax:561-370-7026
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2880202367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305440300Medicaid
FLG1890UMedicare ID - Type Unspecified
FL305440300Medicaid