Provider Demographics
NPI:1306525910
Name:CLARKE, JOHN CHARLES JR (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:CLARKE
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 BUCKINGHAM SQ
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-8568
Mailing Address - Country:US
Mailing Address - Phone:606-584-8080
Mailing Address - Fax:
Practice Address - Street 1:610 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177
Practice Address - Country:US
Practice Address - Phone:937-382-9314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OH363A00000X363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant