Provider Demographics
NPI:1164760476
Name:CLARK, CRYSTAL MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:935 SHOTWELL RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-5597
Mailing Address - Country:US
Mailing Address - Phone:919-550-0821
Mailing Address - Fax:919-550-0735
Practice Address - Street 1:5156 NC HIGHWAY 42 W
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-8417
Practice Address - Country:US
Practice Address - Phone:919-329-5000
Practice Address - Fax:919-329-5300
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04032363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant