Provider Demographics
NPI:1932525284
Name:SMITH, SHAUN
Entity Type:Individual
Prefix:
First Name:SHAUN
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:PO BOX 272195
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80527-2195
Mailing Address - Country:US
Mailing Address - Phone:888-757-1951
Mailing Address - Fax:877-757-1951
Practice Address - Street 1:254 CHAPMAN RD
Practice Address - Street 2:SUITE 112
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-5413
Practice Address - Country:US
Practice Address - Phone:888-757-1951
Practice Address - Fax:877-757-1951
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0003548174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist