Provider Demographics
NPI:1730263922
Name:CLARK, JOSEPH P (PA)
Entity type:Individual
Prefix:
First Name:JOSEPH
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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Mailing Address - Street 1:1025 STONE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-4777
Mailing Address - Country:US
Mailing Address - Phone:785-383-5827
Mailing Address - Fax:785-354-5475
Practice Address - Street 1:801 N 4TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KS
Practice Address - Zip Code:66839-2602
Practice Address - Country:US
Practice Address - Phone:620-364-2121
Practice Address - Fax:620-364-2012
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200305420AMedicaid
P26113Medicare UPIN