Basic Information
| Provider Information | |||||||||
| NPI: | 1285631648 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH-EDE | ||||||||
| FirstName: | BOBBIE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 691 MURPHY RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417898000 | ||||||||
| FaxNumber: | 5417896461 | ||||||||
| Practice Location | |||||||||
| Address1: | 691 MURPHY ROAD SUITE 107 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417896460 | ||||||||
| FaxNumber: | 5417896461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 200250183 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 200250183NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 100163 | 05 | OR | MEDICAID |