Basic Information
| Provider Information | |||||||||
| NPI: | 1003819707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376620009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238572093 | ||||||||
| FaxNumber: | 4233903340 | ||||||||
| Practice Location | |||||||||
| Address1: | 3019 PEOPLES ST # CONDO300 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376041977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234612100 | ||||||||
| FaxNumber: | 4234612199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN7641 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | MS0507890 | 01 | TN | DEA LICENSE | OTHER | 3347731 | 05 | TN | MEDICAID | APN7641 | 01 | TN | ADVANCED PRACTICE NURSE | OTHER | RN115963 | 01 | TN | REGISTER NURSE LICENSE | OTHER |