Basic Information
| Provider Information | |||||||||
| NPI: | 1659952570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | MADISON | ||||||||
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| Credential: | APRN CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1607 STATE RD STE 6 | ||||||||
| Address2: | |||||||||
| City: | VERMILION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440899142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409678713 | ||||||||
| FaxNumber: | 4409671938 | ||||||||
| Practice Location | |||||||||
| Address1: | 1607 STATE RD | ||||||||
| Address2: | |||||||||
| City: | VERMILION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440899142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409678713 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2021 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.0028715 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | APRN.CNP.0028715 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.