Provider Demographics
NPI:1285101246
Name:SMITH, MATTHEW L (RN)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 CERRILLOS RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-1650
Mailing Address - Country:US
Mailing Address - Phone:505-476-6410
Mailing Address - Fax:
Practice Address - Street 1:1060 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1650
Practice Address - Country:US
Practice Address - Phone:505-476-6410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM291816163WS0200X
NMR26377163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM36672548Medicaid