Provider Demographics
NPI:1861498859
Name:CLARK, STEVEN D (RPA-C)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MOUNTAIN LEDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:NY
Mailing Address - Zip Code:12831-1858
Mailing Address - Country:US
Mailing Address - Phone:518-339-4839
Mailing Address - Fax:
Practice Address - Street 1:14 MOUNTAIN LEDGE DRIVE
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:NY
Practice Address - Zip Code:12831-1858
Practice Address - Country:US
Practice Address - Phone:518-339-4839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007751OtherLICENSE
NYP15977Medicare UPIN
NY007751OtherLICENSE
NYDD7009Medicare PIN