Provider Demographics
NPI:1386223170
Name:CLEMONS, MAXIMILIAN GERHARD (RN, BSN, CCRN, CRNA)
Entity type:Individual
Prefix:
First Name:MAXIMILIAN
Middle Name:GERHARD
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:RN, BSN, CCRN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 LONE PINE DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-3344
Mailing Address - Country:US
Mailing Address - Phone:727-418-6644
Mailing Address - Fax:
Practice Address - Street 1:200 SE HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2346
Practice Address - Country:US
Practice Address - Phone:877-463-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9432879390200000X
FL11026244367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program