Provider Demographics
NPI:1811471188
Name:ALLEN, CLAYTON (STUDENT)
Entity type:Individual
Prefix:
First Name:CLAYTON
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3816 CASPIAN DR APT 6
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-6228
Mailing Address - Country:US
Mailing Address - Phone:229-415-0838
Mailing Address - Fax:
Practice Address - Street 1:3816 CASPIAN DR APT 6
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-6228
Practice Address - Country:US
Practice Address - Phone:229-415-0838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA16990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program