Provider Demographics
NPI:1619035029
Name:CLARK, KARMEN RENEE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KARMEN
Middle Name:RENEE
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 1:6212 BROWNING DR.
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564
Mailing Address - Country:US
Mailing Address - Phone:228-238-7443
Mailing Address - Fax:
Practice Address - Street 1:3631 BIENVILLE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5702
Practice Address - Country:US
Practice Address - Phone:228-818-9620
Practice Address - Fax:228-818-9750
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00357210Medicaid
MS00357210Medicaid
MSQ61249Medicare UPIN