Provider Demographics
NPI:1164568135
Name:COURSON, CLARENCE DAVID (PA)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:DAVID
Last Name:COURSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4211 BRIDGEWATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867
Mailing Address - Country:US
Mailing Address - Phone:706-653-2255
Mailing Address - Fax:706-653-2255
Practice Address - Street 1:4519 WOODRUFF RD STE 4 PMB 318
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6096
Practice Address - Country:US
Practice Address - Phone:706-653-2255
Practice Address - Fax:706-653-2329
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS63703Medicare UPIN
GA97BBHHMMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER