Provider Demographics
NPI:1679751200
Name:SOUDER, CLIFFORD C (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:C
Last Name:SOUDER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 BROOKLEY AVE SW
Mailing Address - Street 2:
Mailing Address - City:BOLLING AFB
Mailing Address - State:DC
Mailing Address - Zip Code:20032-7704
Mailing Address - Country:US
Mailing Address - Phone:202-404-6491
Mailing Address - Fax:
Practice Address - Street 1:238 BROOKLEY AVE SW
Practice Address - Street 2:
Practice Address - City:BOLLING AFB
Practice Address - State:DC
Practice Address - Zip Code:20032-7704
Practice Address - Country:US
Practice Address - Phone:202-404-6491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003746363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant