1952451023 NPI number — MR. ERIN SHANE SMILEY CRNA

Table of content: MR. ERIN SHANE SMILEY CRNA (NPI 1952451023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952451023 NPI number — MR. ERIN SHANE SMILEY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMILEY
Provider First Name:
ERIN
Provider Middle Name:
SHANE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952451023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4864 JACKSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71202-6400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-330-7626
Provider Business Mailing Address Fax Number:
318-330-7648

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4864 JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71202-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-330-7626
Provider Business Practice Location Address Fax Number:
318-330-7648
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN084922 APO4149 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1147460 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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