Provider Demographics
NPI:1891092516
Name:CLARK, NATHANIEL ROBERT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:ROBERT
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:NAVAL HOSPITAL 6000 WEST HWY 98
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32512-0003
Mailing Address - Country:US
Mailing Address - Phone:240-898-7288
Mailing Address - Fax:850-505-6288
Practice Address - Street 1:NAVAL HOSPITAL 6000 WEST HWY 98
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32512-0003
Practice Address - Country:US
Practice Address - Phone:240-898-7288
Practice Address - Fax:850-505-6288
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001219375367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered