Provider Demographics
NPI:1174568125
Name:CLARK, RONALD SEVIER (CRNA)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:SEVIER
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 1:5025 AIRPORT CENTER PKWY BLDG L
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5885
Mailing Address - Country:US
Mailing Address - Phone:704-512-7105
Mailing Address - Fax:
Practice Address - Street 1:8800 N TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3300
Practice Address - Country:US
Practice Address - Phone:704-863-5665
Practice Address - Fax:704-863-5848
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC66013367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNAN647Medicaid
NC066013OtherRN LICENSE
NC260712AMedicare PIN
SCNAN647Medicaid
NC8050928Medicaid