Provider Demographics
NPI:1396516910
Name:SMITH, ANDREW WESLEY
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:WESLEY
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 1:1819 SE SOLOMON LOOP
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4631
Mailing Address - Country:US
Mailing Address - Phone:503-841-2052
Mailing Address - Fax:360-334-9955
Practice Address - Street 1:1819 SE SOLOMON LOOP
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4631
Practice Address - Country:US
Practice Address - Phone:503-841-2052
Practice Address - Fax:360-334-9955
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAEXEMPT374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide