Provider Demographics
NPI:1043715212
Name:ROBERTS, CLAYTON CHARLES (SA-C)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:CHARLES
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 PRESCOTT RD STE 202
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3983
Mailing Address - Country:US
Mailing Address - Phone:318-442-0106
Mailing Address - Fax:318-448-8918
Practice Address - Street 1:3311 PRESCOTT RD STE 202
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3983
Practice Address - Country:US
Practice Address - Phone:318-442-0106
Practice Address - Fax:318-448-8918
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI17-640OtherAMERICAN BOARD OF SURGICAL ASSISTANTS