Basic Information
| Provider Information | |||||||||
| NPI: | 1891745428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 993 | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955360993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077869170 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3306 RENNER DR | ||||||||
| Address2: | |||||||||
| City: | FORTUNA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955403120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077256101 | ||||||||
| FaxNumber: | 7077252978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN238330 | CA | X | Nursing Service Providers | Registered Nurse | 363LF0000X | FNP877 | CA | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | MS0516039 | 01 | DEA | OTHER |