Provider Demographics
NPI:1588604722
Name:CLARKE, MARY ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:CLARKE
Suffix:
Gender:F
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 711841
Mailing Address - Street 2:MID ATLANTIC ANESTHESIA CONSULTANTS
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-0001
Mailing Address - Country:US
Mailing Address - Phone:304-346-9400
Mailing Address - Fax:304-345-7320
Practice Address - Street 1:1200 J D ANDERSON DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3494
Practice Address - Country:US
Practice Address - Phone:304-598-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV033774367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001719096OtherMSBCBS
WV001706470OtherMSBCBS
WV0207026000Medicaid
WV270052997004OtherTRICARE
WV27005299700OtherWORKERS COMP
WV0065884000Medicaid
WV9333201Medicare PIN
WV001719096OtherMSBCBS