1700033156 NPI number — MR. JOHN K CLAYSHULTE III PA-C

Table of content: MR. JOHN K CLAYSHULTE III PA-C (NPI 1700033156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700033156 NPI number — MR. JOHN K CLAYSHULTE III PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLAYSHULTE
Provider First Name:
JOHN
Provider Middle Name:
K
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700033156
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7300 RANCH ROAD 2222, BLDG 1, STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78730-3255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-759-8932
Provider Business Mailing Address Fax Number:
512-233-2711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2240 GRANDE BLVD SE STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-1751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-545-6741
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA2014-0058 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 60632876 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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