Basic Information
| Provider Information | |||||||||
| NPI: | 1205852894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUEEN | ||||||||
| FirstName: | CLIFFORD | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404411949 | ||||||||
| FaxNumber: | 7404465982 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404465238 | ||||||||
| FaxNumber: | 7404418058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 155948 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000006912 | 01 | ANTHEM BCBS | OTHER | 0065208000 | 05 | WV | MEDICAID | 430028924 | 01 | RR MEDICARE | OTHER | 001714073 | 01 | MOUNTAIN STATE BCBS | OTHER | 0752118 | 01 | OH | MOLINA MEDICAID | OTHER |