Provider Demographics
NPI:1750343992
Name:SMITH, WAYNE GRAHAM (DC)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:GRAHAM
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5129 ETHAN ALLEN HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-6071
Mailing Address - Country:US
Mailing Address - Phone:864-494-3555
Mailing Address - Fax:802-782-8862
Practice Address - Street 1:158 LAKE ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-2278
Practice Address - Country:US
Practice Address - Phone:864-494-3555
Practice Address - Fax:802-782-8862
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006.0064013111N00000X
VT06.0064013111NR0400X, 111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2393Medicaid
SCGCH365Medicaid
VT001617502OtherMEDICARE PTAN
VT001617502OtherMEDICARE PTAN
SCCH2393Medicaid