Provider Demographics
NPI:1053330480
Name:PRICE, CLINT DAVID (PAC)
Entity Type:Individual
Prefix:MR
First Name:CLINT
Middle Name:DAVID
Last Name:PRICE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S SHARON AMITY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-0035
Mailing Address - Country:US
Mailing Address - Phone:704-377-2424
Mailing Address - Fax:704-377-2687
Practice Address - Street 1:501 S SHARON AMITY RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-0035
Practice Address - Country:US
Practice Address - Phone:704-377-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102155363AM0700X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8974568Medicaid
NC970022487OtherMEDICARE RAILROAD
NCP00155278OtherRR MEDICARE
NC1053330480Medicaid
NC74568OtherNCBCBS
NCS39985Medicare UPIN
NC1053330480Medicaid
NC2749844EMedicare PIN
NC2749844CMedicare PIN
NCP00155278OtherRR MEDICARE
NC2749844BMedicare PIN