Provider Demographics
NPI:1669473153
Name:CLANCY, KERRY (PA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:CLANCY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 GLENSFORD DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-0892
Mailing Address - Country:US
Mailing Address - Phone:910-483-4647
Mailing Address - Fax:910-483-6431
Practice Address - Street 1:217 GLENSFORD DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314
Practice Address - Country:US
Practice Address - Phone:910-483-4647
Practice Address - Fax:910-483-6431
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000102790363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD7406OtherK. CLANCY'S MEDCOST #
NC2752764BMedicare ID - Type UnspecifiedGROUP # 2336501
NCP03799Medicare UPIN