Provider Demographics
NPI:1851361026
Name:CLARK, MICHAEL EUGENE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EUGENE
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 1:309 NW SYRCLE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-3223
Mailing Address - Country:US
Mailing Address - Phone:850-453-8976
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL PENSACOLA
Practice Address - Street 2:6000 WEST HWY 98
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32512-0003
Practice Address - Country:US
Practice Address - Phone:850-505-6762
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2695852367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered