Basic Information
| Provider Information | |||||||||
| NPI: | 1316430564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | E. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 ROANE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253022334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043440096 | ||||||||
| FaxNumber: | 3043424725 | ||||||||
| Practice Location | |||||||||
| Address1: | 4605 MACCORKLE AVE SW | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253091311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047663600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2018 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 118087 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.