Provider Demographics
NPI:1154371771
Name:HARTMAN, CLYDE EDWARD (PA)
Entity type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:EDWARD
Last Name:HARTMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3809 ASHLEY LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-1305
Mailing Address - Country:US
Mailing Address - Phone:817-294-8134
Mailing Address - Fax:
Practice Address - Street 1:300 W ROSEDALE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4856
Practice Address - Country:US
Practice Address - Phone:817-335-2202
Practice Address - Fax:817-882-6595
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00352363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant