Provider Demographics
NPI:1023255940
Name:CLARK, KIM EVANS (CRNA)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:EVANS
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-797-6220
Mailing Address - Fax:864-797-6307
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:2ND FLOOR ANESTHESIA
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5611
Practice Address - Country:US
Practice Address - Phone:864-454-0888
Practice Address - Fax:864-454-1130
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3798367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1970Medicaid
SCAN1970Medicaid