Provider Demographics
NPI:1316170574
Name:CLARK, PATRICIA L (RPA-C)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 ROUTE 25A STE 2
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2014
Mailing Address - Country:US
Mailing Address - Phone:631-929-1256
Mailing Address - Fax:631-929-8313
Practice Address - Street 1:271 ROUTE 25A STE 2
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2014
Practice Address - Country:US
Practice Address - Phone:631-929-1256
Practice Address - Fax:631-929-8313
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013420-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical