MEDICARE: MR. CLINT LEE NESOM CRNA

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	367500000X	Certified Registered Nurse Anesthetist	C01142	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5U298	OTHER	AR	AR BCBS

General Provider Information

NPI Number	:	1578559639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLINT LEE NESOM CRNA

Provider Business Mailing Address
First Line	:	PO BOX 650426
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75265-0426
Country	:	US
Telephone Number	:	972-715-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	13601 PRESTON RD
Second Line	:	STE 1000W
City	:	DALLAS
State	:	TX
Zip	:	75240-4911
Country	:	US
Telephone Number	:	972-715-5000
Fax Number	:

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

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	05/05/2011

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