Provider Demographics
NPI:1073520581
Name:CLARK, MATTHEW HARVEY (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:HARVEY
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:255 N HERWALDT DR
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2186
Practice Address - Country:US
Practice Address - Phone:559-459-7300
Practice Address - Fax:559-459-3750
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003694363A00000X, 363AM0700X
CAPA22496363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8451098Medicaid
WA8859526Medicare PIN
Q67314Medicare UPIN