Provider Demographics
NPI:1366479172
Name:SMITH, BETTY C (CRNFA)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3735 N. TABOR STREET
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215
Mailing Address - Country:US
Mailing Address - Phone:480-699-0155
Mailing Address - Fax:480-699-0155
Practice Address - Street 1:3735 N. TABOR STREET
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215
Practice Address - Country:US
Practice Address - Phone:480-699-0155
Practice Address - Fax:480-699-0155
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN 058867363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z5564OtherHEALTNET OF AZ
AZAZ0168910OtherBCBS AZ
AZ359861Medicaid