Provider Demographics
NPI:1851321251
Name:CLARK, SHANA S (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANA
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:103A SAINT JAMES PL
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16933-1257
Mailing Address - Country:US
Mailing Address - Phone:570-662-7600
Mailing Address - Fax:570-662-7726
Practice Address - Street 1:103A SAINT JAMES PL
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:PA
Practice Address - Zip Code:16933-1257
Practice Address - Country:US
Practice Address - Phone:570-662-7600
Practice Address - Fax:570-662-7726
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060929L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA092572KALMedicare ID - Type UnspecifiedMEDICARE NUMBER