Provider Demographics
NPI:1821094046
Name:CLARK, JOHN HENRY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:HENRY
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 1:5049 AVOCET LN
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-8082
Mailing Address - Country:US
Mailing Address - Phone:850-494-7079
Mailing Address - Fax:
Practice Address - Street 1:5049 AVOCET LN
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-8082
Practice Address - Country:US
Practice Address - Phone:850-494-7079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 3072412367500000X
CTR40669367500000X
AL1-097045367500000X
TX690232367500000X
CARN491358/NA2011367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG2172Medicare ID - Type Unspecified