Provider Demographics
NPI:1154072536
Name:CLARK, NATALIE LOREE (PA-C)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:LOREE
Last Name:CLARK
Suffix:
Gender:F
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 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-366-9232
Mailing Address - Fax:614-366-9217
Practice Address - Street 1:460 W 10TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-3241
Practice Address - Fax:614-293-4044
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50007840RX363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0002271Medicaid