Provider Demographics
NPI:1588838627
Name:CLAUSEN, MITCH ANTHONY
Entity type:Individual
Prefix:
First Name:MITCH
Middle Name:ANTHONY
Last Name:CLAUSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 BRANDENBURG LN
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-2660
Mailing Address - Country:US
Mailing Address - Phone:870-523-8495
Mailing Address - Fax:
Practice Address - Street 1:2501 BRANDENBURG LN
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-2660
Practice Address - Country:US
Practice Address - Phone:870-523-8495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-19
Last Update Date:2008-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR2850377001Medicaid