Provider Demographics
NPI:1689665390
Name:FAIRCLOTH, MICHAEL E (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:FAIRCLOTH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1336 CREEKSIDE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-1931
Mailing Address - Country:US
Mailing Address - Phone:239-261-1158
Mailing Address - Fax:239-261-4232
Practice Address - Street 1:1336 CREEKSIDE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-1931
Practice Address - Country:US
Practice Address - Phone:239-261-1158
Practice Address - Fax:239-261-4232
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1414222367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305214100Medicaid
G0473OtherBCBS