Provider Demographics
NPI:1013671809
Name:SMITH, MATTHEW NATHAN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:NATHAN
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 1:1104 CASS ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3236
Mailing Address - Country:US
Mailing Address - Phone:231-941-1155
Mailing Address - Fax:231-259-1005
Practice Address - Street 1:1104 CASS ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3236
Practice Address - Country:US
Practice Address - Phone:231-941-1155
Practice Address - Fax:231-259-1005
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704306664363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care