Basic Information
| Provider Information | |||||||||
| NPI: | 1487139770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | G | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 12TH AVE N STE 140W | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591017507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062386726 | ||||||||
| FaxNumber: | 4062386599 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 12TH AVE N STE 140W | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591017507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062375050 | ||||||||
| FaxNumber: | 4062386599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 07/03/2019 | ||||||||
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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 | 363A00000X | 70013 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 70013 | 01 | MT | LICENSE | OTHER | P02235881 | 01 | MT | RAILROAD MEDICARE | OTHER | MS5103813 | 01 | MT | DEA | OTHER |