Provider Demographics
NPI:1164746954
Name:CLARKE, CHARLES MCCARROL (RN)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MCCARROL
Last Name:CLARKE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 BROADWAY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4045
Mailing Address - Country:US
Mailing Address - Phone:718-726-5953
Mailing Address - Fax:718-204-5308
Practice Address - Street 1:3811 BROADWAY
Practice Address - Street 2:3RD FLOOR
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4045
Practice Address - Country:US
Practice Address - Phone:718-726-5953
Practice Address - Fax:718-204-5308
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY544350163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse