Provider Demographics
NPI:1427484096
Name:HARVEY, CLYDE KENNETH JR (CSA)
Entity type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:KENNETH
Last Name:HARVEY
Suffix:JR
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 AUTUMN MOON
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-1378
Mailing Address - Country:US
Mailing Address - Phone:210-725-8783
Mailing Address - Fax:
Practice Address - Street 1:1307 AUTUMN MOON
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-1378
Practice Address - Country:US
Practice Address - Phone:210-725-8783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4195246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant