Provider Demographics
NPI:1972711141
Name:CLARK, SANDRA B (CRNA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8212 SUMMA AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3421
Mailing Address - Country:US
Mailing Address - Phone:225-769-4403
Mailing Address - Fax:225-769-4403
Practice Address - Street 1:8212 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3421
Practice Address - Country:US
Practice Address - Phone:225-769-4403
Practice Address - Fax:225-769-4403
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN039057 AP01415367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA59668Medicare ID - Type UnspecifiedMEDICARE