Provider Demographics
NPI:1225542558
Name:CLARK, CASEY DANIEL (NP)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:DANIEL
Last Name:CLARK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 SHERATON BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1358
Mailing Address - Country:US
Mailing Address - Phone:478-474-2947
Mailing Address - Fax:478-971-8149
Practice Address - Street 1:230 SHERATON BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1358
Practice Address - Country:US
Practice Address - Phone:478-474-2947
Practice Address - Fax:478-971-8149
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN214247363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner