Provider Demographics
NPI:1326874074
Name:SMITH, PHILLIP WAYNE (APRN)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 E GOLDEN WILLOW CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4217
Mailing Address - Country:US
Mailing Address - Phone:817-480-8131
Mailing Address - Fax:
Practice Address - Street 1:4770 S 900 E STE 209
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4616
Practice Address - Country:US
Practice Address - Phone:817-480-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8991411-4405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care