Provider Demographics
NPI:1669944088
Name:SMITH, ANDREW BRYAN (CRNA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:BRYAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 SAVANNAH CT
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3682
Mailing Address - Country:US
Mailing Address - Phone:517-281-6529
Mailing Address - Fax:
Practice Address - Street 1:7575 GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9309
Practice Address - Country:US
Practice Address - Phone:810-844-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-24
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI124782367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704287625OtherSTATE RN LICENSE
WI238552-30OtherSTATE RN LICENSE