Provider Demographics
NPI:1225119191
Name:CLARK, SCOTT EARL (RPAC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:EARL
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-1814
Mailing Address - Country:US
Mailing Address - Phone:585-344-2749
Mailing Address - Fax:
Practice Address - Street 1:6 FOUNTAIN PLAZA
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202
Practice Address - Country:US
Practice Address - Phone:716-691-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007724-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant