Provider Demographics
NPI:1881659258
Name:CLARK, CHAD DAVID (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:DAVID
Last Name:CLARK
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 DRUGAN CT SW
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-8181
Mailing Address - Country:US
Mailing Address - Phone:614-314-3020
Mailing Address - Fax:614-627-2014
Practice Address - Street 1:85 MCNAUGHTEN RD
Practice Address - Street 2:STE 110
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2174
Practice Address - Country:US
Practice Address - Phone:614-856-9100
Practice Address - Fax:614-856-9191
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-1851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CLPA20203Medicare ID - Type Unspecified
P74635Medicare UPIN