Provider Demographics
NPI:1144245358
Name:SMITH, PHILLIP (NP)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 9TH STREET, ROOM 150
Mailing Address - Street 2:FISCAL ALLOCATIONS AND ESTIMATES UNIT
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6414
Mailing Address - Country:US
Mailing Address - Phone:916-651-9475
Mailing Address - Fax:916-651-8908
Practice Address - Street 1:10333 E CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-5808
Practice Address - Country:US
Practice Address - Phone:805-468-2000
Practice Address - Fax:805-468-6011
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 484213163W00000X
CANP 8636363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WNP8636LMedicare UPIN