Provider Demographics
NPI:1750090759
Name:SMITH, IAN
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
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 1:1800 FORT WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE GLEN
Mailing Address - State:PA
Mailing Address - Zip Code:19002-3025
Mailing Address - Country:US
Mailing Address - Phone:215-407-7643
Mailing Address - Fax:
Practice Address - Street 1:1800 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MAPLE GLEN
Practice Address - State:PA
Practice Address - Zip Code:19002-3025
Practice Address - Country:US
Practice Address - Phone:215-407-7643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2023-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1686630163W00000X
COAPN.0998313-CRNA367500000X
PAPA669910163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1992Medicaid