Provider Demographics
NPI:1609858166
Name:CLARK, ALISON L (CNM)
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 CALLE DE ALEGRA
Mailing Address - Street 2:BLDG. A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:385 CALLE DE ALEGRA BLDG C
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3423
Practice Address - Country:US
Practice Address - Phone:575-556-8200
Practice Address - Fax:575-521-7199
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR868545367A00000X
LAAP03090367A00000X
NM696367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM58003827Medicaid
NM414370YRNDOtherMEDICARE
LA1699617Medicaid
AL569100085Medicaid
LA1699617Medicaid
S55832Medicare UPIN
330081YU5FMedicare PIN