Provider Demographics
NPI:1851820773
Name:SMITH, JUSTIN MICHAEL (DNP)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 W CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6123
Mailing Address - Country:US
Mailing Address - Phone:534-200-6165
Mailing Address - Fax:
Practice Address - Street 1:1002 W CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6123
Practice Address - Country:US
Practice Address - Phone:534-200-6155
Practice Address - Fax:534-200-6166
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI185099163W00000X
OR202207051163W00000X
MN11108363LF0000X
MNR-212530-7163W00000X
NY974938163W00000X
IAW164201364S00000X
OR202207118CNS-PP364S00000X
NY356671363LF0000X
MO2022030124364S00000X
WI7951-33364S00000X, 363LF0000X
WAAP61288318364S00000X
AZ283150364S00000X
MN538364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist