Basic Information
| Provider Information | |||||||||
| NPI: | 1245349075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ALYSON | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERRY | ||||||||
| OtherFirstName: | ALYSON | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4320 WORNALL RD | ||||||||
| Address2: | SUITE 50-II | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641115941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169313312 | ||||||||
| FaxNumber: | 8165319862 | ||||||||
| Practice Location | |||||||||
| Address1: | 4320 WORNALL RD | ||||||||
| Address2: | SUITE 50-II | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641115941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169313312 | ||||||||
| FaxNumber: | 8165319862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 09/02/2008 | ||||||||
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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 | 363AS0400X | 2002027389 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 200004760A | 05 | KS | MEDICAID |