Provider Demographics
NPI:1588657571
Name:BANCROFT, CLINTON (CRNA)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:BANCROFT
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 1:1434 N MORNINGSIDE DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3240
Mailing Address - Country:US
Mailing Address - Phone:404-876-1514
Mailing Address - Fax:
Practice Address - Street 1:3200 DOWNWOOD CIR NW
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1610
Practice Address - Country:US
Practice Address - Phone:404-355-8721
Practice Address - Fax:404-355-8797
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN035321367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA43ZCBXD01Medicare ID - Type UnspecifiedPROVIDER NUMBER