Healthcare Provider Details

I. General information

NPI: 1881408169
Provider Name (Legal Business Name): MICHAEL PAUL CLANCY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 LEXINGTON RD
GEORGETOWN KY
40324-9330
US

IV. Provider business mailing address

3701 MARINER DR
EVANSVILLE IN
47711-7029
US

V. Phone/Fax

Practice location:
  • Phone: 502-868-1100
  • Fax:
Mailing address:
  • Phone: 706-993-0780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4035089
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: