Provider Demographics
NPI:1508899170
Name:CLARK, BONNIE (PA C)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
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 1:5400 GIBSON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4729
Mailing Address - Country:US
Mailing Address - Phone:505-262-7026
Mailing Address - Fax:505-727-9276
Practice Address - Street 1:5400 GIBSON BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4729
Practice Address - Country:US
Practice Address - Phone:505-262-7026
Practice Address - Fax:505-727-9276
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM79-PA004363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59428Medicaid
NM341417401Medicare ID - Type Unspecified
NM59428Medicaid