Basic Information
| Provider Information | |||||||||
| NPI: | 1811994254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KIRK | ||||||||
| MiddleName: | MACDONALD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 MYRTLE ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417733863 | ||||||||
| FaxNumber: | 5416184413 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 MYRTLE ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417733863 | ||||||||
| FaxNumber: | 5416184413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 09/09/2011 | ||||||||
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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 | 363LF0000X | 200150032 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 227698 | 05 | OR | MEDICAID |