Provider Demographics
NPI:1588198766
Name:TABB, CLARENCE (CSA)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:
Last Name:TABB
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 GREENS LN
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 E 33RD ST
Practice Address - Street 2:SUITE 487
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-3322
Practice Address - Country:US
Practice Address - Phone:410-554-2780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1925246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant