Basic Information
| Provider Information | |||||||||
| NPI: | 1821729914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | BON | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1541 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504317816 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1541 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504317816 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2022 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11020362 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.