Provider Demographics
NPI:1598777450
Name:CLARK, LONNIE W (CRNA)
Entity Type:Individual
Prefix:
First Name:LONNIE
Middle Name:W
Last Name:CLARK
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 1:420 PAISLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8205
Mailing Address - Country:US
Mailing Address - Phone:806-790-3928
Mailing Address - Fax:
Practice Address - Street 1:16420 W US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-8760
Practice Address - Country:US
Practice Address - Phone:806-790-3928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX690859367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179419001Medicaid
OK200073510AMedicaid
CO90739868Medicaid
TX67349Medicaid
TX147825100Medicaid
NM202004266Medicaid
TX147825101OtherFIRSTCARE COMMERCIAL
TX86092UOtherBC/BS
NM202004266OtherPRESBYTERIAN COMMERCIAL
TX86091UOtherHMO BLUE
NM64851729Medicaid
OK200073510AMedicaid
TX147825100Medicaid
NM64851729Medicaid