Provider Demographics
NPI:1376283218
Name:CLARK, RYAN RADWIN (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:RADWIN
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 LAKE EDEN RD
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-8707
Mailing Address - Country:US
Mailing Address - Phone:704-770-5527
Mailing Address - Fax:
Practice Address - Street 1:181 LAKE EDEN RD
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-8707
Practice Address - Country:US
Practice Address - Phone:704-770-5527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical