Provider Demographics
NPI:1477036291
Name:CLARK, CHRISTOPHER WILLIAM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:WILLIAM
Last Name:CLARK
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 1:701 E COUNTY LINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1070
Mailing Address - Country:US
Mailing Address - Phone:317-885-2860
Mailing Address - Fax:317-885-2869
Practice Address - Street 1:701 E COUNTY LINE RD STE 101
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1070
Practice Address - Country:US
Practice Address - Phone:317-885-2860
Practice Address - Fax:317-885-2869
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002612A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300020884Medicaid