Provider Demographics
NPI:1578509386
Name:STREAM, CLARK REED (PA-C)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:REED
Last Name:STREAM
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 1:120 N RICHARD JACKSON BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2522
Mailing Address - Country:US
Mailing Address - Phone:505-326-1688
Mailing Address - Fax:505-326-5688
Practice Address - Street 1:120 N RICHARD JACKSON BLVD STE 140
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2522
Practice Address - Country:US
Practice Address - Phone:850-532-6168
Practice Address - Fax:850-532-6568
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100951363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290567101Medicaid
FLS80453Medicare UPIN