Healthcare Provider Details

I. General information

NPI: 1467754267
Provider Name (Legal Business Name): CLAY B AWISHES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N MACOMB ST
MONROE MI
48162-7815
US

IV. Provider business mailing address

718 N MACOMB ST
MONROE MI
48162-7815
US

V. Phone/Fax

Practice location:
  • Phone: 734-240-8536
  • Fax:
Mailing address:
  • Phone: 734-240-8536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.12044
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704229730
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: