Provider Demographics
NPI:1679531024
Name:SMITH, KEVIN LEE (DNP)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:18510 25TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-2016
Mailing Address - Country:US
Mailing Address - Phone:763-639-5327
Mailing Address - Fax:
Practice Address - Street 1:6655 CORTLAWN CIR S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55426-1557
Practice Address - Country:US
Practice Address - Phone:763-639-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR096446-3363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500002690Medicare UPIN