Provider Demographics
NPI:1821541152
Name:CLARK, MARY OLIVIA (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:OLIVIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 48089
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-8089
Mailing Address - Country:US
Mailing Address - Phone:706-389-3740
Mailing Address - Fax:706-389-3951
Practice Address - Street 1:2142 W BROAD ST, BLDG 100, STE 200
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3509
Practice Address - Country:US
Practice Address - Phone:706-548-6881
Practice Address - Fax:706-546-0821
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8057363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical