Basic Information
| Provider Information | |||||||||
| NPI: | 1396211991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | QUENTIN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | QUENTIN | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068106077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037397000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068106099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037397000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2018 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 185989 | CT | N | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 163WC0200X | RN2330179 | MA | N | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 367500000X | RN2330179 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 10289 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 110150127A | 05 | MA | MEDICAID |