Provider Demographics
NPI:1023524196
Name:SMITH, CASEY JOE (FNPC)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:JOE
Last Name:SMITH
Suffix:
Gender:M
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 S 950 W
Mailing Address - Street 2:
Mailing Address - City:HEYBURN
Mailing Address - State:ID
Mailing Address - Zip Code:83336-9765
Mailing Address - Country:US
Mailing Address - Phone:801-564-4479
Mailing Address - Fax:844-965-9279
Practice Address - Street 1:312 S 950 W
Practice Address - Street 2:
Practice Address - City:HEYBURN
Practice Address - State:ID
Practice Address - Zip Code:83336-9765
Practice Address - Country:US
Practice Address - Phone:801-484-4479
Practice Address - Fax:844-965-9279
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID70138363LF0000X
UT7273597-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily