Provider Demographics
NPI:1679735930
Name:CLARK, PATRICIA MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MICHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:WV
Mailing Address - Zip Code:25136-2116
Mailing Address - Country:US
Mailing Address - Phone:304-442-2521
Mailing Address - Fax:304-442-7463
Practice Address - Street 1:401 6TH AVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:WV
Practice Address - Zip Code:25136-2116
Practice Address - Country:US
Practice Address - Phone:304-442-2521
Practice Address - Fax:304-442-7463
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine