Basic Information
| Provider Information | |||||||||
| NPI: | 1891114906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMART | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 287 | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436100 | ||||||||
| FaxNumber: | 9075436008 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 CHIEF EDDIE HOFFMAN | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436100 | ||||||||
| FaxNumber: | 9075436008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2014 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
ID Information
| ID | Type | State | Issuer | Description | 1020986 | 05 | AK | MEDICAID |