Provider Demographics
NPI:1760559033
Name:CLARK, DORA K (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:DORA
Middle Name:K
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:207 QUAKER LN
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-2283
Mailing Address - Country:US
Mailing Address - Phone:401-828-7110
Mailing Address - Fax:401-825-6029
Practice Address - Street 1:207 QUAKER LN
Practice Address - Street 2:
Practice Address - City:WEST WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02893-2283
Practice Address - Country:US
Practice Address - Phone:401-828-7110
Practice Address - Fax:401-827-6364
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIPA00430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDC95067Medicaid
RIP01280388OtherRAILROAD MCR
RI1760559033OtherNEIGHBORHOOD HEALTH PLAN
RI2509391OtherCOVENTRY
RI7674984OtherAETNA
RIP01280388OtherRAILROAD MCR