Provider Demographics
NPI:1407189194
Name:GODFREY, CLARENCE LAMAR (PAAA)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:LAMAR
Last Name:GODFREY
Suffix:
Gender:
Credentials:PAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 N POINT PKWY
Mailing Address - Street 2:BUILDING F, SUITE 100
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5481
Mailing Address - Country:US
Mailing Address - Phone:770-645-9181
Mailing Address - Fax:770-645-8455
Practice Address - Street 1:2540 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8605
Practice Address - Country:US
Practice Address - Phone:470-644-1274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-12
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005632367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I320298Medicare PIN