Provider Demographics
NPI:1710968763
Name:CLARK, STACEY (PA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:ORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:PENACOOK
Mailing Address - State:NH
Mailing Address - Zip Code:03303-1412
Mailing Address - Country:US
Mailing Address - Phone:603-753-4302
Mailing Address - Fax:
Practice Address - Street 1:4 CRESCENT ST.
Practice Address - Street 2:
Practice Address - City:PENACOOK
Practice Address - State:NH
Practice Address - Zip Code:03303-1412
Practice Address - Country:US
Practice Address - Phone:603-753-4302
Practice Address - Fax:603-227-7570
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2511363AM0700X
NH0622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3073660Medicaid
S80279Medicare UPIN
NH30335239Medicaid
MAAP1043Medicare PIN
NH0001323Medicare PIN
NH000132301Medicare PIN