Provider Demographics
NPI:1184603268
Name:SMITH, KEVIN DOUGLAS (RN, MN, NP-C)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN, MN, NP-C
Other - Prefix:
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Mailing Address - Street 1:606 E CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-8909
Mailing Address - Country:US
Mailing Address - Phone:509-299-4854
Mailing Address - Fax:
Practice Address - Street 1:4815 N ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6185
Practice Address - Country:US
Practice Address - Phone:509-434-7941
Practice Address - Fax:509-434-7115
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAAP30006383363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMS0927814OtherDEA