Provider Demographics
NPI:1275923781
Name:CLARK, JONATHAN B (CRNA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:CLARK
Suffix:
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 1:333 RICCIUTI DR
Mailing Address - Street 2:APT. 1824
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-6287
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-4575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN277232367500000X
RIAPRN00302367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110106160AMedicaid
MAS400206092Medicare PIN
MA110106160AMedicaid