Provider Demographics
NPI:1740256544
Name:CLARK, RONALD B (CRNA)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:B
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:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65302-1547
Mailing Address - Country:US
Mailing Address - Phone:660-826-5960
Mailing Address - Fax:660-826-4852
Practice Address - Street 1:600 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-5304
Practice Address - Country:US
Practice Address - Phone:256-543-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-030288367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL170074Medicaid
AL511-57668OtherBCBS
AL170074Medicaid
AL102I438116Medicare PIN