Provider Demographics
NPI:1851575393
Name:SMITH, GERALD LEE (CRNA)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 PINE STREET
Mailing Address - Street 2:1ST MEDICAL GROUP
Mailing Address - City:LANGLEY AFB
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2080
Mailing Address - Country:US
Mailing Address - Phone:757-487-4733
Mailing Address - Fax:757-487-4733
Practice Address - Street 1:45 PINE STREET
Practice Address - Street 2:1ST MEDICAL GROUP
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-2080
Practice Address - Country:US
Practice Address - Phone:757-487-4733
Practice Address - Fax:757-487-4733
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024053447174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist