Provider Demographics
NPI:1376765925
Name:CLARK, ROBERT (NP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 BIRCH CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-6510
Mailing Address - Country:US
Mailing Address - Phone:734-474-6325
Mailing Address - Fax:
Practice Address - Street 1:EMPLOYEE AND OCCUPATIONAL HEALTH
Practice Address - Street 2:MEDICAL CENTER BOULEVARD
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:734-474-6325
Practice Address - Fax:336-716-6127
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006585363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health