Basic Information
| Provider Information | |||||||||
| NPI: | 1750634754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLACK | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 PEACHTREE STREET | ||||||||
| Address2: | DAVIS FISCHER BUILDING OFFICE 330 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30308 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | DAVIS FISCHER BUILDING OFFICE 330 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046867858 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2012 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.