Provider Demographics
NPI:1407860166
Name:CLARK, MELISSA D (PA C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13020 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0925
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:813-558-6186
Practice Address - Street 1:909 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1251
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-978-9700
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2015-02-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9102703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292088300Medicaid
Q42704Medicare UPIN
FLU4676ZMedicare PIN