Provider Demographics
NPI:1285631887
Name:CLARK, MARK D (FNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BARRETT ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-1356
Mailing Address - Country:US
Mailing Address - Phone:770-540-4274
Mailing Address - Fax:
Practice Address - Street 1:102 BARRETT ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-1356
Practice Address - Country:US
Practice Address - Phone:770-540-4274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN128712363L00000X, 363LA2200X, 363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1738523OtherWELLCARE
GA06423272OtherAMERIGROUP
GA615230572CMedicaid
GA615230572EMedicaid
GA615230572FMedicaid
GA615230572DMedicaid