Basic Information
| Provider Information | |||||||||
| NPI: | 1669110359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMYTH | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 808 W LAUREL AVE APT 1 | ||||||||
| Address2: | |||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934365239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135901615 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 315 CAMINO DEL REMEDIO | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931101332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056815244 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y4612372 | CA | Y |
No ID Information.