Healthcare Provider Details

I. General information

NPI: 1740511005
Provider Name (Legal Business Name): CLINTON M ANDERSON MT, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W HORIZON RIDGE PKWY STE 100
HENDERSON NV
89052-5014
US

IV. Provider business mailing address

PO BOX 778413
HENDERSON NV
89077-8413
US

V. Phone/Fax

Practice location:
  • Phone: 702-357-8811
  • Fax: 702-947-5352
Mailing address:
  • Phone: 702-357-8811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number260790928
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: