Provider Demographics
NPI:1841228889
Name:CLARK, JOHN D (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4 GLEN COVE DR STE 206
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4239
Mailing Address - Country:US
Mailing Address - Phone:207-921-5454
Mailing Address - Fax:207-921-5353
Practice Address - Street 1:39 MILES ST.
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-0000
Practice Address - Country:US
Practice Address - Phone:207-563-1040
Practice Address - Fax:207-563-1039
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2018-11-07
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Provider Licenses
StateLicense IDTaxonomies
MEPA-319363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME115501Medicare PIN
MES04584Medicare UPIN