Provider Demographics
NPI:1326006834
Name:CLARK, MICHAEL G (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 AIRPORT FWY STE 305
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-6604
Mailing Address - Country:US
Mailing Address - Phone:817-545-1355
Mailing Address - Fax:817-545-1574
Practice Address - Street 1:1305 AIRPORT FWY STE 305
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6604
Practice Address - Country:US
Practice Address - Phone:817-545-1355
Practice Address - Fax:817-545-1574
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196349801Medicaid
TX196349804Medicaid
TX8N2840OtherBCBS
TX196349803Medicaid
TXP00297373OtherRAILROAD MEDICARE
TX196349802Medicaid
TX8N2840OtherBCBS
TX196349802Medicaid
TX196349803Medicaid
TX196349804Medicaid
TXTXB103071Medicare PIN