Provider Demographics
NPI:1649214131
Name:CLARK, JULIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-5600
Mailing Address - Fax:208-302-5655
Practice Address - Street 1:10255 OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1430
Practice Address - Country:US
Practice Address - Phone:208-302-5600
Practice Address - Fax:208-302-5655
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805414100Medicaid
ID805414100Medicaid
ID1666347Medicare ID - Type Unspecified