Provider Demographics
NPI:1558697854
Name:CLARK, LADONNA BROWN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LADONNA
Middle Name:BROWN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2544 COURT DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3450
Mailing Address - Country:US
Mailing Address - Phone:704-671-6400
Mailing Address - Fax:704-671-6449
Practice Address - Street 1:2544 COURT DR
Practice Address - Street 2:SUITE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-671-6400
Practice Address - Fax:704-671-6449
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-01974363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1558697854Medicaid
SC1151PAMedicaid
NC1558697854Medicaid
NC2762737Medicare PIN