Provider Demographics
NPI:1114917168
Name:CLEMENTS, DAVID H (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:H
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4424 E FLAMINGO AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-288-4700
Practice Address - Fax:208-288-4720
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA500363A00000X
IDPA-500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010147756OtherBLUE SHIELD
IDPANZY7OtherBLUE CROSS
IDP00159990OtherRAILROAD MEDICARE
ID806955800Medicaid
IDPANY9OtherBLUE CROSS
IDP00159990OtherRAILROAD MEDICARE
IDPANY9OtherBLUE CROSS