Provider Demographics
NPI:1417375411
Name:CLARK, EMMA
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 17TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-7200
Mailing Address - Country:US
Mailing Address - Phone:202-398-5520
Mailing Address - Fax:202-396-6353
Practice Address - Street 1:801 17TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-7200
Practice Address - Country:US
Practice Address - Phone:202-398-5520
Practice Address - Fax:202-396-6353
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1022317367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F30407Medicare UPIN