Basic Information
| Provider Information | |||||||||
| NPI: | 1700033156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLAYSHULTE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6601 VAUGHT RANCH RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787302309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126280465 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 2240 GRANDE BLVD SE STE 106 | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871241751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055456741 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2008 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2014-0058 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 60632876 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.