Basic Information
| Provider Information | |||||||||
| NPI: | 1255477659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1621 SHASTA ST | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082383229 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 444 HOSPITAL WAY | ||||||||
| Address2: | SUITE 801 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082326214 | ||||||||
| FaxNumber: | 2082333416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 06/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N34646 | ID | Y | Nursing Service Providers | Registered Nurse |
No ID Information.