Provider Demographics
NPI:1861505026
Name:CLARK, MARK E (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 5576
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-5576
Mailing Address - Country:US
Mailing Address - Phone:423-926-6266
Mailing Address - Fax:423-926-7599
Practice Address - Street 1:101 MED TECH PKWY
Practice Address - Street 2:SUITE 305
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4007
Practice Address - Country:US
Practice Address - Phone:423-926-6266
Practice Address - Fax:423-926-7599
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA942363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P48678Medicare UPIN