Provider Demographics
NPI:1437779360
Name:ROMANEK, CLAY MATTHEW (PA-C)
Entity Type:Individual
Prefix:
First Name:CLAY
Middle Name:MATTHEW
Last Name:ROMANEK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4181 108TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-7439
Mailing Address - Country:US
Mailing Address - Phone:763-581-5952
Mailing Address - Fax:
Practice Address - Street 1:11855 ULYSSES ST NE STE 120
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3948
Practice Address - Country:US
Practice Address - Phone:763-581-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MN13641363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant