Provider Demographics
NPI:1770583924
Name:CLARK, BEVERLY ANNE-MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANNE-MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:P.O. BOX 2000
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057
Mailing Address - Country:US
Mailing Address - Phone:315-362-5129
Mailing Address - Fax:315-362-5179
Practice Address - Street 1:321 GENESEE ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421
Practice Address - Country:US
Practice Address - Phone:315-361-2342
Practice Address - Fax:315-361-2043
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3527951174400000X
NY352795367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR0A641Medicare ID - Type Unspecified