Individual
JERRY CLARKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
200 COMMODORE ST, PRATT, KS 67124-2903
(620) 672-7451
(316) 652-0340
Mailing address
PO BOX 1919, WICHITA, KS 67201-1919
(316) 685-3698
(316) 652-0340
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
54408
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
012137
BCBS
KS
05
—
100143840C
—
KS
05
—
200029270A
—
OK
01
—
430001730
RAILROAD MEDICARE
—
Enumeration date
03/10/2006
Last updated
10/04/2011
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