Provider Demographics
NPI:1245319250
Name:ROYSTON, CLINT P (MS, MSN)
Entity type:Individual
Prefix:MR
First Name:CLINT
Middle Name:P
Last Name:ROYSTON
Suffix:
Gender:M
Credentials:MS, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 AURORA AVE
Mailing Address - Street 2:STE 401E
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-2800
Mailing Address - Country:US
Mailing Address - Phone:515-331-0303
Mailing Address - Fax:515-331-9086
Practice Address - Street 1:6200 AURORA AVE
Practice Address - Street 2:STE 401E
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-2800
Practice Address - Country:US
Practice Address - Phone:515-331-0303
Practice Address - Fax:515-331-9086
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG-116306363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA10658701Medicaid