Provider Demographics
NPI:1093737439
Name:CLARK, JULIE (PA)
Entity Type:Individual
Prefix:MISS
First Name:JULIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 NORTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0689
Mailing Address - Country:US
Mailing Address - Phone:918-647-2349
Mailing Address - Fax:918-641-2359
Practice Address - Street 1:307 NORTH BROADWAY
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-0689
Practice Address - Country:US
Practice Address - Phone:918-647-2349
Practice Address - Fax:918-641-2359
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OK1528363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200089790AMedicaid
OK200089790AMedicaid