Provider Demographics
NPI:1730170796
Name:CLARK, GREGORY P (PA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:P
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435
Mailing Address - Country:US
Mailing Address - Phone:307-754-3405
Mailing Address - Fax:307-754-1207
Practice Address - Street 1:777 AVENUE H
Practice Address - Street 2:POWELL VALLEY HEALTHCARE INC
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435
Practice Address - Country:US
Practice Address - Phone:307-754-3405
Practice Address - Fax:307-754-1207
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WY203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115812100Medicaid
WY115812100Medicaid