Provider Demographics
NPI:1508951435
Name:CLARK, LEVON SR (PA)
Entity Type:Individual
Prefix:MR
First Name:LEVON
Middle Name:
Last Name:CLARK
Suffix:SR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5788 ECKHERT RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3900
Mailing Address - Country:US
Mailing Address - Phone:210-699-2280
Mailing Address - Fax:210-699-2250
Practice Address - Street 1:5788 ECKHERT RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3900
Practice Address - Country:US
Practice Address - Phone:210-699-2280
Practice Address - Fax:210-699-2250
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02702363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant