Provider Demographics
NPI:1568439537
Name:CLARK, DARIN T (PA-C)
Entity Type:Individual
Prefix:
First Name:DARIN
Middle Name:T
Last Name:CLARK
Suffix:
Gender:M
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 1:1189 PARALLEL ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2216
Mailing Address - Country:US
Mailing Address - Phone:810-629-0949
Mailing Address - Fax:
Practice Address - Street 1:102 N ADELAIDE ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2670
Practice Address - Country:US
Practice Address - Phone:810-629-2245
Practice Address - Fax:810-629-6535
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMC0921785OtherMEDICARE RR ID
MIW44784Medicare UPIN
MIMC0921785OtherMEDICARE RR ID