Basic Information
| Provider Information | |||||||||
| NPI: | 1164760476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 935 SHOTWELL RD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275205597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195500821 | ||||||||
| FaxNumber: | 9195500735 | ||||||||
| Practice Location | |||||||||
| Address1: | 5156 NC HIGHWAY 42 W | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275298417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193295000 | ||||||||
| FaxNumber: | 9193295300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2013 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-04032 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.