Provider Demographics
NPI:1588028310
Name:STEPHENS, CLINTON (CRNA)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:STEPHENS
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 1:4620 S DERBIGNY ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-5014
Mailing Address - Country:US
Mailing Address - Phone:361-649-6905
Mailing Address - Fax:
Practice Address - Street 1:2500 BELLE CHASSE HWY
Practice Address - Street 2:
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-7127
Practice Address - Country:US
Practice Address - Phone:504-391-5157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN139455390200000X
LAAP08879367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09523777Medicaid
LA2428535Medicaid
LA529640YH3UMedicare PIN