Provider Demographics
NPI:1184604670
Name:MARTIN, CLYDE DONALD JR (CRNA)
Entity type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:DONALD
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:CRNA
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Mailing Address - Street 1:68 S SERVICE RD STE 350
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2358
Mailing Address - Country:US
Mailing Address - Phone:865-342-8940
Mailing Address - Fax:
Practice Address - Street 1:87 MCGREGOR ST
Practice Address - Street 2:STE. 1400
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3765
Practice Address - Country:US
Practice Address - Phone:603-647-9325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166498367500000X
NC4017367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH001216501Medicare PIN