Provider Demographics
NPI:1245207679
Name:MICKLISH, CLARA JO (CRNA)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:JO
Last Name:MICKLISH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-8501
Mailing Address - Country:US
Mailing Address - Phone:814-226-3416
Mailing Address - Fax:814-226-1457
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-8501
Practice Address - Country:US
Practice Address - Phone:814-226-3416
Practice Address - Fax:814-226-1457
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN173315L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA054676Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER