Provider Demographics
NPI:1760449821
Name:COLLINS, CLARK A (PA-C)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:A
Last Name:COLLINS
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-0249
Mailing Address - Country:US
Mailing Address - Phone:920-568-5411
Mailing Address - Fax:920-568-4004
Practice Address - Street 1:1504 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-3100
Practice Address - Country:US
Practice Address - Phone:920-563-7888
Practice Address - Fax:920-563-7741
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1029-023363AS0400X, 363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI60272OtherDEAN HEALTH INSURANCE
WI42974300Medicaid
WIP00224733Medicare PIN
WI087674150Medicare PIN
WI42974300Medicaid