Provider Demographics
NPI:1174740138
Name:EPPS, CLYDE A (PA)
Entity type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:A
Last Name:EPPS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 ISLAND GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MAXTON
Mailing Address - State:NC
Mailing Address - Zip Code:28364-7840
Mailing Address - Country:US
Mailing Address - Phone:910-374-5415
Mailing Address - Fax:
Practice Address - Street 1:506 ISLAND GROVE RD
Practice Address - Street 2:
Practice Address - City:MAXTON
Practice Address - State:NC
Practice Address - Zip Code:28364-7840
Practice Address - Country:US
Practice Address - Phone:910-374-5415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104169364SP0808X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0169OtherGROUP
2762403Medicare ID - Type Unspecified
Q32535Medicare UPIN