Provider Demographics
NPI:1720198922
Name:CLARK, ROBERT D (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
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:PO BOX 53864
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3864
Mailing Address - Country:US
Mailing Address - Phone:337-289-2966
Mailing Address - Fax:337-289-2776
Practice Address - Street 1:611 SAINT LANDRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4627
Practice Address - Country:US
Practice Address - Phone:337-289-2966
Practice Address - Fax:337-289-2776
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2021367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1393185Medicaid
LA59740Medicare PIN