Basic Information
| Provider Information | |||||||||
| NPI: | 1003540501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARSON | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | JOE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 724 W GREEN HILL ST | ||||||||
| Address2: | |||||||||
| City: | PIEDMONT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639571100 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 PIEDMONT AVE | ||||||||
| Address2: | |||||||||
| City: | PIEDMONT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639571024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732234233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2022 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2022026858 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.