Provider Demographics
NPI:1568475523
Name:CLARK, MARIEL (PA,C)
Entity Type:Individual
Prefix:PROF
First Name:MARIEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA,C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:9501 ROOSEVELT BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1025
Mailing Address - Country:US
Mailing Address - Phone:215-969-4917
Mailing Address - Fax:215-969-5875
Practice Address - Street 1:9501 ROOSEVELT BLVD
Practice Address - Street 2:SUITE 410
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1025
Practice Address - Country:US
Practice Address - Phone:215-969-4917
Practice Address - Fax:215-969-5875
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMA000134L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant