Provider Demographics
NPI:1992147615
Name:CLARK, SAVANNAH A (CRNA)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-9210
Mailing Address - Country:US
Mailing Address - Phone:417-533-6100
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9210
Practice Address - Country:US
Practice Address - Phone:417-533-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013026436367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MOP01235238OtherRR MCR
MO1992147615Medicaid
AR199441001Medicaid
MO132680434Medicare PIN
MO1992147615Medicaid