Provider Demographics
NPI:1366079493
Name:SMITH, CHRISTIAN
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2656 TIGER LN
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-8001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST STE 303
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6768
Practice Address - Country:US
Practice Address - Phone:800-548-6672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12366062-1501213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program