Provider Demographics
NPI:1063411023
Name:CLARK, ROBERT JOEL (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOEL
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 HORNER ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-6113
Mailing Address - Country:US
Mailing Address - Phone:304-266-7064
Mailing Address - Fax:
Practice Address - Street 1:2000 VENTURE TOWER DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:866-439-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06044363A00000X
WV584363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD151474Y1ZMedicare PIN
MDP00773804Medicare PIN
S44068Medicare UPIN