Provider Demographics
NPI:1750634754
Name:CLACK, JUSTIN PHILIP (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PHILIP
Last Name:CLACK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 PEACHTREE STREET
Mailing Address - Street 2:DAVIS FISCHER BUILDING OFFICE 330
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:242 KING AVE STE 130
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-613-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6639207RP1001X, 207X00000X, 207XX0801X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma