Provider Demographics
NPI:1285819318
Name:CLARK, BARBARA LATREASE (PA-C)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:LATREASE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:LATREASE
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 RIDGELEY
Mailing Address - Street 2:#4
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016
Mailing Address - Country:US
Mailing Address - Phone:323-932-9646
Mailing Address - Fax:323-932-9646
Practice Address - Street 1:2401 RIDGELEY
Practice Address - Street 2:#4
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016
Practice Address - Country:US
Practice Address - Phone:323-932-9646
Practice Address - Fax:323-932-9646
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19103363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA19103OtherMEDICAL BOARD OF CA