Provider Demographics
NPI:1174534085
Name:CLARK, CASEY RYAN (CRNA)
Entity type:Individual
Prefix:MR
First Name:CASEY
Middle Name:RYAN
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 1:22234 KENNEMER LN
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613-8162
Mailing Address - Country:US
Mailing Address - Phone:256-206-2081
Mailing Address - Fax:256-771-5972
Practice Address - Street 1:22234 KENNEMER LN
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613-8162
Practice Address - Country:US
Practice Address - Phone:256-206-2081
Practice Address - Fax:256-771-5972
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-104686367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered