Provider Demographics
NPI:1417942657
Name:CLEM, MARK S (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:CLEM
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 1:304 WRIGHT ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SWEETWATER
Mailing Address - State:TN
Mailing Address - Zip Code:37874-1181
Mailing Address - Country:US
Mailing Address - Phone:865-632-5900
Mailing Address - Fax:865-546-5227
Practice Address - Street 1:9125 CROSS PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4505
Practice Address - Country:US
Practice Address - Phone:865-632-5900
Practice Address - Fax:865-546-5227
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA110001634363A00000X
TNPA1617363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010184487Medicaid
VA007371A130Medicare ID - Type Unspecified
VA010184487Medicaid
TN3665290Medicare PIN