Provider Demographics
NPI:1639187230
Name:CLARKE, SHAUN M (PA-C)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:M
Last Name:CLARKE
Suffix:
Gender:M
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:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:MI
Mailing Address - Zip Code:48742-0279
Mailing Address - Country:US
Mailing Address - Phone:989-736-8157
Mailing Address - Fax:
Practice Address - Street 1:177 N BARLOW RD
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48740-9607
Practice Address - Country:US
Practice Address - Phone:989-736-8157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004561363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC56002071Medicare ID - Type Unspecified