Provider Demographics
NPI:1932109105
Name:CLARK, RICHARD O (PAC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:O
Last Name:CLARK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 N E ST
Mailing Address - Street 2:SUITE 331
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-6339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 N E ST
Practice Address - Street 2:SUITE 331
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6339
Practice Address - Country:US
Practice Address - Phone:850-444-1717
Practice Address - Fax:850-444-1755
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA000270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS59820Medicare UPIN
FLE1017ZMedicare ID - Type Unspecified