Basic Information
| Provider Information | |||||||||
| NPI: | 1477196012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMIDDY | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 COLLIER ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787042911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124274357 | ||||||||
| FaxNumber: | 5127031394 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 AIRPORT BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787023152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127031365 | ||||||||
| FaxNumber: | 5128043457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2019 | ||||||||
| LastUpdateDate: | 10/31/2019 | ||||||||
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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 | 798313 | TX | Y | Nursing Service Providers | Registered Nurse |
No ID Information.