Provider Demographics
NPI:1265046932
Name:SMITH, ERIC WAYNE
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:WAYNE
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 1:367 S GULPH RD
Mailing Address - Street 2:ATN :IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:806-340-0550
Mailing Address - Fax:806-513-6790
Practice Address - Street 1:1301 S COULTER ST
Practice Address - Street 2:SUITE 200
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-7910
Practice Address - Country:US
Practice Address - Phone:806-340-0550
Practice Address - Fax:806-513-6790
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144510363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1Q4045OtherPTAN