Basic Information
| Provider Information | |||||||||
| NPI: | 1316170574 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 271 ROUTE 25A STE 2 | ||||||||
| Address2: | |||||||||
| City: | WADING RIVER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117922014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319291256 | ||||||||
| FaxNumber: | 6319298313 | ||||||||
| Practice Location | |||||||||
| Address1: | 271 ROUTE 25A STE 2 | ||||||||
| Address2: | |||||||||
| City: | WADING RIVER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117922014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319291256 | ||||||||
| FaxNumber: | 6319298313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2009 | ||||||||
| LastUpdateDate: | 09/03/2009 | ||||||||
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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 | 363AM0700X | 013420-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.