Provider Demographics
NPI:1073808721
Name:CLEMENTS, JOSHUA GLEN (RSA)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:GLEN
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30907 CORRECT CRAFT LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60481-2147
Mailing Address - Country:US
Mailing Address - Phone:815-545-7750
Mailing Address - Fax:
Practice Address - Street 1:10039 BISSONNET ST STE 250
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-7852
Practice Address - Country:US
Practice Address - Phone:815-545-7750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000287246ZC0007X, 246ZS0410X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical