Provider Demographics
NPI:1285983247
Name:CLARK, SAMUEL JASON (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:JASON
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2283 BLAKERS BLVD
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29909-7808
Mailing Address - Country:US
Mailing Address - Phone:513-582-2485
Mailing Address - Fax:
Practice Address - Street 1:1 PINCKNEY BLVD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6122
Practice Address - Country:US
Practice Address - Phone:843-228-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1002X
NC0010-11081363A00000X
1161440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman