Basic Information
| Provider Information | |||||||||
| NPI: | 1184604670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | CLYDE | ||||||||
| MiddleName: | DONALD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD STE 350 | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653428940 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 87 MCGREGOR ST | ||||||||
| Address2: | STE. 1400 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031023765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036479325 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 0024166498 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 4017 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.