Provider Demographics
NPI:1629027974
Name:CLARK, TIMOTHY (RPA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 505
Mailing Address - Street 2:
Mailing Address - City:NORTH CHILI
Mailing Address - State:NY
Mailing Address - Zip Code:14514
Mailing Address - Country:US
Mailing Address - Phone:585-594-5995
Mailing Address - Fax:585-594-5425
Practice Address - Street 1:4201 BUFFALO ROAD
Practice Address - Street 2:
Practice Address - City:NORTH CHILI
Practice Address - State:NY
Practice Address - Zip Code:14514
Practice Address - Country:US
Practice Address - Phone:585-594-5995
Practice Address - Fax:585-594-5425
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010708363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant