Provider Demographics
NPI:1225588171
Name:CLARK, VANESSA (PA-C, RD)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 FOX POND DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4850
Mailing Address - Country:US
Mailing Address - Phone:843-901-4563
Mailing Address - Fax:
Practice Address - Street 1:2511 OLD CORNWALLIS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-1869
Practice Address - Country:US
Practice Address - Phone:919-932-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06800363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical