Provider Demographics
NPI:1316965874
Name:SMITH, DEBRA JO BAUER (CRNA)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:JO BAUER
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:B
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:212 BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-1913
Mailing Address - Country:US
Mailing Address - Phone:256-426-1622
Mailing Address - Fax:
Practice Address - Street 1:14 HAWTHORNE PARK CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3194
Practice Address - Country:US
Practice Address - Phone:864-331-0364
Practice Address - Fax:864-331-0370
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-025651367500000X
SC20039367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51526491OtherBCBS #
AL051526491Medicare ID - Type UnspecifiedMEDICARE #
AL51526491OtherBCBS #
AL051526491Medicare ID - Type UnspecifiedMEDICAID #
R76072Medicare UPIN