Provider Demographics
NPI:1952040552
Name:CLARK, PORTER GRACE (PA-C)
Entity Type:Individual
Prefix:
First Name:PORTER
Middle Name:GRACE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2306 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4404
Mailing Address - Country:US
Mailing Address - Phone:540-255-5501
Mailing Address - Fax:850-250-0022
Practice Address - Street 1:2306 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4404
Practice Address - Country:US
Practice Address - Phone:850-250-0021
Practice Address - Fax:850-250-0022
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2024-02-13
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant