Provider Demographics
NPI:1225703853
Name:CLARK-LARUE, TRESTON GRANT (PA-C)
Entity Type:Individual
Prefix:
First Name:TRESTON
Middle Name:GRANT
Last Name:CLARK-LARUE
Suffix:
Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:142 WESTWICK LN APT 19
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2732
Mailing Address - Country:US
Mailing Address - Phone:814-241-3992
Mailing Address - Fax:
Practice Address - Street 1:4350 US 421 S
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-6760
Practice Address - Country:US
Practice Address - Phone:910-893-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant