Basic Information
| Provider Information | |||||||||
| NPI: | 1598741357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMENTS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 READS WAY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NEW CASTLE | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197201630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027094709 | ||||||||
| FaxNumber: | 3027094551 | ||||||||
| Practice Location | |||||||||
| Address1: | 4755 OGLETOWN STANTON ROAD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197181320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027331000 | ||||||||
| FaxNumber: | 3027332685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 01/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | RN334205L | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | L6-0A00734 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1598741357 | 05 | DE | MEDICAID |