Provider Demographics
NPI:1134651987
Name:CLARK, JOSHUA MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:MICHAEL
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 1:2600 FM 1764 RD
Mailing Address - Street 2:STE 190
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-2826
Mailing Address - Country:US
Mailing Address - Phone:281-886-8964
Mailing Address - Fax:409-440-8071
Practice Address - Street 1:720 ROLLINGBROOK ST
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-4059
Practice Address - Country:US
Practice Address - Phone:281-420-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11086363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant