Provider Demographics
NPI:1649236472
Name:CLARK, DEBRA DOUBLET (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:DOUBLET
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 1:1609 W 40TH AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6329
Mailing Address - Country:US
Mailing Address - Phone:870-534-3449
Mailing Address - Fax:870-535-3973
Practice Address - Street 1:1609 W 40TH AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6329
Practice Address - Country:US
Practice Address - Phone:870-534-3449
Practice Address - Fax:870-535-3973
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R98138Medicare UPIN
AR54822P020Medicare ID - Type Unspecified