=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184604670
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLYDE DONALD MARTIN JR. CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2006
-----------------------------------------------------
Last Update Date | 06/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 87 MCGREGOR ST STE. 1400
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03102-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-647-9325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 68 S SERVICE RD STE 350
-----------------------------------------------------
City | MELVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11747-2358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-342-8940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 0024166498
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 4017
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------