Basic Information
| Provider Information | |||||||||
| NPI: | 1285605451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMOLEY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MD, MPH, FAAFP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 S KITSAP BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608745900 | ||||||||
| FaxNumber: | 3608745959 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 S KITSAP BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608745900 | ||||||||
| FaxNumber: | 3608745959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 40476-020 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD61112177 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2175430 | 05 | WA | MEDICAID |