Provider Demographics
NPI:1700889409
Name:SMITH, JUSTIN WARREN (CRNA)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:WARREN
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-540-3341
Mailing Address - Fax:502-540-3393
Practice Address - Street 1:200 ABRAHAM FLEXNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-587-4404
Practice Address - Fax:502-587-4156
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2018-08-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN166747163W00000X
IN71001350A363LF0000X
IL041315277367500000X
KY3004228367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200388540Medicaid
KY7100372420Medicaid
KYK1838900-KOHMGOtherKY MEDICARE
IN212540IMedicare PIN