Provider Demographics
NPI:1487682498
Name:CLARK, DOUGLAS MARLEY (PAC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MARLEY
Last Name:CLARK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 S ROANE ST
Mailing Address - Street 2:
Mailing Address - City:HARRIMAN
Mailing Address - State:TN
Mailing Address - Zip Code:37748-8653
Mailing Address - Country:US
Mailing Address - Phone:865-590-0072
Mailing Address - Fax:865-590-0069
Practice Address - Street 1:2317 S ROANE ST
Practice Address - Street 2:COMMUNITY CARE WALK IN CLINIC
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748-8653
Practice Address - Country:US
Practice Address - Phone:865-590-0072
Practice Address - Fax:865-590-0069
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA000000019363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3723702Medicaid
R93277Medicare UPIN
TN3723702Medicaid