Provider Demographics
NPI:1114291051
Name:HEIDLER, CLARE D IV (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CLARE
Middle Name:D
Last Name:HEIDLER
Suffix:IV
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1497 FAIR RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0822
Mailing Address - Country:US
Mailing Address - Phone:912-486-1973
Mailing Address - Fax:912-681-4184
Practice Address - Street 1:1497 FAIR RD
Practice Address - Street 2:SUITE 102
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0822
Practice Address - Country:US
Practice Address - Phone:912-486-1973
Practice Address - Fax:912-681-4184
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC205653163W00000X
SC088676367500000X
SC19789367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGAN309Medicaid