Provider Demographics
NPI:1619360351
Name:CLARKE, EDWINA (MD)
Entity Type:Individual
Prefix:MRS
First Name:EDWINA
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W CRESCENT PARK
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2111
Mailing Address - Country:US
Mailing Address - Phone:814-730-8000
Mailing Address - Fax:
Practice Address - Street 1:2 W CRESCENT PARK
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2199
Practice Address - Country:US
Practice Address - Phone:814-723-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD470063208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program