Provider Demographics
NPI:1417706623
Name:CLARK, SAMUEL (AGACNP)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3566 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICA
Mailing Address - State:DE
Mailing Address - Zip Code:19946-1265
Mailing Address - Country:US
Mailing Address - Phone:302-632-7359
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 2E99
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-5982
Practice Address - Fax:302-733-6081
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0048020163W00000X
DELP-0010513363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology