Provider Demographics
NPI:1205385655
Name:CLARK, CHASITY (PA)
Entity Type:Individual
Prefix:MISS
First Name:CHASITY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHASITY
Other - Middle Name:
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:405 BELCHER ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35042-2946
Mailing Address - Country:US
Mailing Address - Phone:205-926-2992
Mailing Address - Fax:205-316-7675
Practice Address - Street 1:405 BELCHER ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:AL
Practice Address - Zip Code:35042-2946
Practice Address - Country:US
Practice Address - Phone:205-926-2992
Practice Address - Fax:205-316-7675
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant