Provider Demographics
NPI:1083039085
Name:CLARK, STEPHEN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 E HAINES ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-1533
Mailing Address - Country:US
Mailing Address - Phone:215-438-1095
Mailing Address - Fax:
Practice Address - Street 1:1013 E HAINES ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-1533
Practice Address - Country:US
Practice Address - Phone:215-438-1095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013599364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health