Provider Demographics
NPI:1942747704
Name:SMITH, MARK (CRNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:22469 BIRCHFIELD GROVE LANE
Mailing Address - Street 2:
Mailing Address - City:NEW CANEY
Mailing Address - State:TX
Mailing Address - Zip Code:77357-1632
Mailing Address - Country:US
Mailing Address - Phone:256-541-0562
Mailing Address - Fax:
Practice Address - Street 1:22469 BIRCHFIELD GROVE LANE
Practice Address - Street 2:
Practice Address - City:NEW CANEY
Practice Address - State:TX
Practice Address - Zip Code:77357-1632
Practice Address - Country:US
Practice Address - Phone:256-541-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023119363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-137155OtherSTATE OF ALABAMA