Provider Demographics
NPI:1609247444
Name:CLARK, KARA M (PA-C)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
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 1:124 WYNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-4231
Mailing Address - Country:US
Mailing Address - Phone:203-740-2593
Mailing Address - Fax:203-740-8250
Practice Address - Street 1:304 FEDERAL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2418
Practice Address - Country:US
Practice Address - Phone:203-740-2593
Practice Address - Fax:203-740-8250
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003391363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical