Provider Demographics
NPI:1538793880
Name:CLOUD, CLINTON MICHAEL
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:MICHAEL
Last Name:CLOUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:3800 S NATIONAL AVE STE 510
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5284
Practice Address - Country:US
Practice Address - Phone:417-875-3160
Practice Address - Fax:417-875-3410
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220081103Medicaid