Provider Demographics
NPI:1306021803
Name:CLARK, SARAH (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:FOUNTAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4201
Mailing Address - Country:US
Mailing Address - Phone:203-488-6358
Mailing Address - Fax:203-481-5327
Practice Address - Street 1:960 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3730
Practice Address - Country:US
Practice Address - Phone:203-488-6358
Practice Address - Fax:203-481-5327
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant