Basic Information
| Provider Information | |||||||||
| NPI: | 1245319250 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROYSTON | ||||||||
| FirstName: | CLINT | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., M.S.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6200 AURORA AVE | ||||||||
| Address2: | STE 401E | ||||||||
| City: | URBANDALE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503222800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5153310303 | ||||||||
| FaxNumber: | 5153319086 | ||||||||
| Practice Location | |||||||||
| Address1: | 6200 AURORA AVE | ||||||||
| Address2: | STE 401E | ||||||||
| City: | URBANDALE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503222800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5153310303 | ||||||||
| FaxNumber: | 5153319086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 06/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | G-116306 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 10658701 | 05 | IA | MEDICAID |