Provider Demographics
NPI:1558339010
Name:CLARKSON, JERRY (CRNA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:CLARKSON
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:PO BOX 1919
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-1919
Mailing Address - Country:US
Mailing Address - Phone:316-685-3698
Mailing Address - Fax:316-652-0340
Practice Address - Street 1:200 COMMODORE ST
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-2903
Practice Address - Country:US
Practice Address - Phone:620-672-7451
Practice Address - Fax:316-652-0340
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54408367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100143840CMedicaid
KS012137OtherBCBS
OK200029270AMedicaid
430001730OtherRAILROAD MEDICARE
OK200029270AMedicaid
430001730OtherRAILROAD MEDICARE