Provider Demographics
NPI:1033190533
Name:CLARK, RICK C JR (PA)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:C
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:PA
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Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-0126
Mailing Address - Country:US
Mailing Address - Phone:208-766-2231
Mailing Address - Fax:208-766-4819
Practice Address - Street 1:220 BANNOCK ST
Practice Address - Street 2:SUITE 306
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-1256
Practice Address - Country:US
Practice Address - Phone:208-766-2600
Practice Address - Fax:208-766-4258
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2021-11-16
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Provider Licenses
StateLicense IDTaxonomies
IDPA-749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP75163Medicare UPIN