Provider Demographics
NPI:1942767173
Name:SMITH, DERRICK WADE
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:WADE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8670 SILVER SHORES DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-2153
Mailing Address - Country:US
Mailing Address - Phone:775-621-6187
Mailing Address - Fax:
Practice Address - Street 1:8670 SILVER SHORES DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-2153
Practice Address - Country:US
Practice Address - Phone:775-621-6187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-24
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12042117133747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty