Provider Demographics
NPI:1275851867
Name:SMITH, EVAN ERNEST (AAS, LMT)
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:ERNEST
Last Name:SMITH
Suffix:
Gender:M
Credentials:AAS, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 NE 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4469
Mailing Address - Country:US
Mailing Address - Phone:541-788-0595
Mailing Address - Fax:
Practice Address - Street 1:1314 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4469
Practice Address - Country:US
Practice Address - Phone:541-788-0595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10819174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist