Provider Demographics
NPI:1689863805
Name:CLARK, DENNIS J (PA-C)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:J
Last Name:CLARK
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 1:1850 E PARK AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-6705
Mailing Address - Country:US
Mailing Address - Phone:814-865-3566
Mailing Address - Fax:814-863-7803
Practice Address - Street 1:1850 E PARK AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6705
Practice Address - Country:US
Practice Address - Phone:814-865-3566
Practice Address - Fax:814-863-7803
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA052887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA052887OtherLICENSE
PA416742Medicare PIN