Provider Demographics
NPI:1619549128
Name:CLARK, JULIA MERCY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:MERCY
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 1:15 S MAIN ST STE 150
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 S MAIN ST STE 150
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6627
Practice Address - Country:US
Practice Address - Phone:716-483-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026751-01363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical