Basic Information
| Provider Information | |||||||||
| NPI: | 1245776160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCKLEAR CLARK | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ASHLEIGH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 296 | ||||||||
| Address2: | |||||||||
| City: | BRYSON CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287130296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104100010 | ||||||||
| FaxNumber: | 8285384441 | ||||||||
| Practice Location | |||||||||
| Address1: | 1521 OWEN PARK LN | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102237420 | ||||||||
| FaxNumber: | 9102237452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2017 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-06943 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | NCW457A | 01 | NC | MEDICARE PTAN | OTHER | 1245776160 | 05 | NC | MEDICAID |