Provider Demographics
NPI:1619061561
Name:CLARK, PATRICIA K (CRNA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:K
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7641 ANGEL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-9602
Mailing Address - Country:US
Mailing Address - Phone:740-589-2790
Mailing Address - Fax:
Practice Address - Street 1:375 DIXMYTH AVENUE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2475
Practice Address - Country:US
Practice Address - Phone:513-872-2432
Practice Address - Fax:513-872-8857
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150049367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered