Provider Demographics
NPI:1821680067
Name:CLARK, CASSIDY RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:RAE
Last Name:CLARK
Suffix:
Gender:F
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:MEDICAL CENTER BOULEVARD 7TH FLOOR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-7768
Mailing Address - Country:US
Mailing Address - Phone:336-716-3182
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BOULEVARD 7TH FLOOR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-7768
Practice Address - Country:US
Practice Address - Phone:336-716-3182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant