Provider Demographics
NPI:1871701847
Name:CLAYTON, JON RUSSELL (PA)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:RUSSELL
Last Name:CLAYTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504-0839
Mailing Address - Country:US
Mailing Address - Phone:919-894-1740
Mailing Address - Fax:919-894-2701
Practice Address - Street 1:1 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504-1177
Practice Address - Country:US
Practice Address - Phone:919-894-1740
Practice Address - Fax:919-894-2701
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC104211OtherSTATE LICENSE
NC104211OtherSTATE LICENSE