Provider Demographics
NPI:1588308258
Name:PAGE, CLARK DELONA (PA)
Entity type:Individual
Prefix:MR
First Name:CLARK
Middle Name:DELONA
Last Name:PAGE
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-656-2218
Mailing Address - Fax:262-653-5850
Practice Address - Street 1:9697 SAINT CATHERINES DR # 300
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-2118
Practice Address - Country:US
Practice Address - Phone:262-656-3338
Practice Address - Fax:262-656-3368
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2024-05-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXPA15731363AM0700X
WI7708-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical