Provider Demographics
NPI:1205902236
Name:CLARK, MICAH SHEA
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:SHEA
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5059
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37831-5059
Mailing Address - Country:US
Mailing Address - Phone:770-237-1089
Mailing Address - Fax:770-237-1124
Practice Address - Street 1:990 OAK RIDGE TPKE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6976
Practice Address - Country:US
Practice Address - Phone:931-858-6303
Practice Address - Fax:931-858-6305
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN075331367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered