Provider Demographics
NPI:1407903693
Name:CLARK, MARK ALLEN
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22445 CONSERVANCY DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-8068
Mailing Address - Country:US
Mailing Address - Phone:540-368-1044
Mailing Address - Fax:540-368-1033
Practice Address - Street 1:111 PARK HILL DR # A
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3357
Practice Address - Country:US
Practice Address - Phone:540-368-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166868363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics