Provider Demographics
NPI:1558545459
Name:CLARKE, AMY E (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:E
Other - Last Name:CLARKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1400 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5156
Mailing Address - Country:US
Mailing Address - Phone:516-338-5300
Mailing Address - Fax:516-333-1075
Practice Address - Street 1:100 PT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576
Practice Address - Country:US
Practice Address - Phone:516-629-2479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010808363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant