Provider Demographics
NPI:1659627354
Name:CLARK, LINDSEY JOHNSON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LINDSEY
Middle Name:JOHNSON
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 1:1693 SW CHANDLER AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3231
Mailing Address - Country:US
Mailing Address - Phone:541-382-8819
Mailing Address - Fax:
Practice Address - Street 1:1693 SW CHANDLER AVE STE 250
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3231
Practice Address - Country:US
Practice Address - Phone:541-382-8819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA199666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010438900Medicaid
FLHL259YMedicare PIN