Provider Demographics
NPI:1184649337
Name:FAWCETT, CLIFFORD W III (CNP)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:W
Last Name:FAWCETT
Suffix:III
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 DAYTON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1777
Mailing Address - Country:US
Mailing Address - Phone:937-767-7291
Mailing Address - Fax:937-767-1302
Practice Address - Street 1:888 DAYTON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1777
Practice Address - Country:US
Practice Address - Phone:937-767-7291
Practice Address - Fax:937-767-1302
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP004512B363LF0000X
OHNP 10074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3108872Medicaid
PAQ74402Medicare UPIN
PA106220Medicare ID - Type Unspecified
OH3108872Medicaid