Provider Demographics
NPI:1154659894
Name:CLARK, HOLLIS JOHNSON JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:HOLLIS
Middle Name:JOHNSON
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4787 ALBEN BARKLEY DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-6789
Mailing Address - Country:US
Mailing Address - Phone:270-442-9461
Mailing Address - Fax:270-441-0079
Practice Address - Street 1:510 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-997-6800
Practice Address - Fax:618-997-1187
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2017-02-23
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Provider Licenses
StateLicense IDTaxonomies
KYTC051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant