Provider Demographics
NPI:1982605739
Name:CLARK, WILLIAM A (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:3413 WOODS EDGE
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-5901
Mailing Address - Country:US
Mailing Address - Phone:517-349-3303
Mailing Address - Fax:517-349-4374
Practice Address - Street 1:2380 CEDAR ST
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-2143
Practice Address - Country:US
Practice Address - Phone:517-742-4922
Practice Address - Fax:517-699-2904
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2015-06-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601001772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0C36097OtherTRAVELERS MEDICARE
MI0C360971062OtherMEDICARE
0C36097OtherBCBS MICHIGAN
MIS97041Medicare UPIN
MI0853301370OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI1046804OtherMCLAREN HEALTH PLAN-COMMERCIAL
MIN61290014Medicare PIN
MIP00861521OtherRAILROAD MEDICARE
MI1046804OtherMCLAREN HEALTH ADVANTAGE