Basic Information
| Provider Information | |||||||||
| NPI: | 1306967187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 W OAKLAWN RD | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780644033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8305698940 | ||||||||
| FaxNumber: | 8305698320 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 10TH ST STE 140 | ||||||||
| Address2: | |||||||||
| City: | FLORESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781143167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8303931747 | ||||||||
| FaxNumber: | 8303931749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 678694 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP115720 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 206717501 | 05 | TX | MEDICAID |