Provider Demographics
NPI:1477068435
Name:WERNER, CLINTON THOMAS (CRNA)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:THOMAS
Last Name:WERNER
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 1:10317 HACKAMORE CIR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8205
Mailing Address - Country:US
Mailing Address - Phone:178-939-1588
Mailing Address - Fax:
Practice Address - Street 1:2300 LONE STAR RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8744
Practice Address - Country:US
Practice Address - Phone:817-939-1588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX814395163W00000X
TXAP136339367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty