MEDICARE: MR. CLYDE KENNETH HARVEY JR. CSA

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	246ZC0007X	Surgical Assistant	4195	TX

General Provider Information

NPI Number	:	1427484096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLYDE KENNETH HARVEY JR. CSA

Provider Business Mailing Address
First Line	:	1307 AUTUMN MOON
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245-1378
Country	:	US
Telephone Number	:	210-725-8783
Fax Number	:

Provider Business Practice Location Address
First Line	:	1307 AUTUMN MOON
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245-1378
Country	:	US
Telephone Number	:	210-725-8783
Fax Number	:

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

Provider Enumeration Date	:	09/16/2013
Last Update Date	:	05/08/2018

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