MEDICARE: MR. CHARLES LAMAR CLAYTON CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	ARNP1859402	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00352522	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	G0150	OTHER	FL	BLUE CROSS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609848894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES LAMAR CLAYTON CRNA

Provider Business Mailing Address
First Line	:	1848 VINELAND LN
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32317-7924
Country	:	US
Telephone Number	:	850-519-1113
Fax Number	:	850-656-5549

Provider Business Practice Location Address
First Line	:	1848 VINELAND LN
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32317-7924
Country	:	US
Telephone Number	:	850-519-1113
Fax Number	:	850-656-5549

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	02/05/2009

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