Provider Demographics
NPI:1598772147
Name:CLARK, TAMARA L (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:L
Other - Last Name:HOLSING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8055 O ST
Mailing Address - Street 2:STE 300
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2580
Mailing Address - Country:US
Mailing Address - Phone:402-421-0896
Mailing Address - Fax:402-421-0945
Practice Address - Street 1:6050 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-4714
Practice Address - Country:US
Practice Address - Phone:402-421-8581
Practice Address - Fax:402-421-8594
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1170363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE37948OtherBCBS
245805OtherMIDLANDS CHOICE
245805OtherMIDLANDS CHOICE
Q41914Medicare UPIN
P00338776Medicare PIN
279216Medicare PIN